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IONIC    SURGERY 


IN   THE   TREATMENT 
OF   CANCER 


With  a  Chapter  on  Ionization  in  Surgical 
Tuberculosis  and  in  Hemorrhoids 


By  G.  BETTON  MASSEY,  M.D. 

ATTENDING     SURGEON     TO     THE    AMERICAN     ONCOLOGIC     HOSPITAL;     AUTHOR 

"  CONSERVATIVE   GYNECOLOGY  AND  ELECTRO-THERAPEUTICS  "  ; 

FELLOW  AND  FORMER  PRESIDENT  OF   THE  AMERICAN 

ELECTRO-THERAPEUTIC  ASSOCIATION  ; 

MEMBER   OF  THE  AMERICAN 

MEDICAL   ASSOCIATION  ; 

ETC.,   ETC. 


NEW  YORK 
THE  A.  L.  CHATTERTON  CO. 

1910 


:0 


Copyright   1910 

BY 

G.    BETTON  MASSEY,  M.D. 


PREFACE. 

This  work  embodies  the  results  of  sixteen  years'  surgical 
employment  of  the  electrically  diffused  ions  of  zinc  and  mer- 
cury in  the  destructive  sterilization  of  cancerous  growths,  and 
contains  a  description  of  the  latest  technical  and  operative  de- 
tails of  the  method,  which  was  first  presented  to  the  medical 
world  by  the  author  in  a  paper  read  before  the  Philadelphia 
County  Medical  Society  January  9,  1895,  and  published  in  the 
Medical  News  in  the  following  March.  To  this  technical  con- 
sideration of  the  subject  is  appended  a  detailed  report  of  all 
cases  treated,  whether  the  results  were  successful  or  not,  ar- 
ranged in  accordance  with  the  portion  of  the  body  affected. 
Believing  that  the  recent  increase  in  the  attention  bestowed  on 
cancerous  affections  warrants  it,  a  brief  recapitulation  of  the 
known  facts  concerning  these  affections  is  given  in  the  first 
portion  of  the  book.  A  final  chapter  has  been  added  on  the 
ionic  treatment  of  tubercular  adenitis  and  of  hemorrhoids. 

While  the  report  of  a  large  number  of  cases  of  cancer  may 
be  dry  reading  to  some  who  may  peruse  these  pages,  it  was 
considered  necessary  to  picture  the  results  in  full,  for  the 
method,  though  still  a  new  one,  has  been  employed  for  a  suf- 
ficient time  to  obtain  results  by  which  to  test  the  claims  made 
for  it.  A  statement  of  these  claims  will  be  found  in  Chapter 
VIIL  The  case  histories,  moreover,  should  be  of  particular 
value  to  those  who  have  begun  to  use  the  method  or  who  pro- 
pose doing  so,  making  it  possible  for  them  to  avoid  the  errors 
and  mistakes  of  the  originator  of  the  procedure. 

In  compiling  these  notes  of  cases,  with  their  final  termina- 
tions or  the  present  conditions  of  their  subjects,  the  author 
has  thought  it  best  to  confine  himself  to  his  personal  experi- 
ence alone,  on  account  of  the  extra  labor  involved  in  ascer- 
taining the  present  condition  of  the  patients  reported  by  others, 
though  he  is  w^ell  informed  of  the  successful  use  of  major 
ionic  operations  for  cancer  by  a  number  of  colleagues,  of 
whom  the  most  notable  are :  Dr.  Amedee  Granger,  of  New 


iv  Preface. 

Orleans,  who  has  reported  his  results  in  a  large  number  of 
cases  in  several  communications  to  state  and  national  societies, 
which  were  duly  published  in  the  medical  press ;  Dr.  Frederick 
C.  Keck,  of  San  Francisco,  Calif.;  Dr.  Frank  E.  Peckham,  of 
Providence,  R.  I. ;  Dr.  Frederick  O.  Marsh,  of  Cincinnati, 
Ohio;  Dr.  W.  D.  McFee,of  Haverhill,  Mass.;  Dr.  R.  Wiss, 
of  Meridian,  Miss. ;  Dr.  C.  R.  Dickson,  of  Toronto,  Can. ;  Dr. 
A.  R.  Pingle,  of  London,  Ontario,  Can.,  and  others.  Descrip- 
tions of  the  method  are  also  contained  in  Boardman  Reed's 
work  on  "  Diseases  of  the  Stomach  and  Intestines,"  and  in  H. 
Lewis  Jones'  work  on  "  Electro-Therapeutics." 

A  portion  of  the  book  has  appeared  in  serial  form  in  the 
pages  of  The  Journal  of  Advanced  Therapeutics,  New  York, 
and  of  Archives  of  the  Roentgen  Ray,  London,  England. 

One  of  the  motives  uppermost  in  the  author's  mind  in  the 
preparation  of  this  work  was  the  hope  that  it  would  be  the 
means  of  calling  renewed  attention  to  the  early  stages  of  can- 
cerous growths,  that  earlier  diagnoses  may  be  made,  and  the 
patients  brought  under  treatment  during  this  favorable  period ; 
for,  though  the  call  for  early  diagnosis  and  treatment  has 
become  a  conspicuous  note  in  the  recent  literature  of  malignant 
disease,  it  is  believed  that  a  great  awakening  is  still  needed,  in 
order  that  this  increasing  menace  to  humanity  may  be  robbed 
of  some,  at  least,  of  its  victims  while  we  are  waiting  for  that 
clearer  knowledge  of  its  nature  that  will  lead  to  effective 
prevention. 

183 1    Chestnut   St.,   Philadelphia. 


CONTENTS. 


INTRODUCTORY 


CHAPTER  I 

The  Nature  of  Malignant  Growths 

Cellular  nature  and  histologic  characteristics — Classification — 
Nature  of  the  cancerous  process — The  autocytic  theory — The 
parasitic  theory — Clinical  evidences  that  cancer  is  due  to 
the  invasion  of  an  extrinsic  germ 


CHAPTER  n 

The  Search  for  Possible  Cancer  Germs 

Soil  conditions — Alode  of  infection — Life  history — Local  dis- 
semination— Regional  dissemination — General  dissemination   ,       lo 

CHAPTER  HI 

The  Differential  Diagnosis  of  Malignant  Growths 

Clinical  evidences  of  malignancy  and  of  the  species  of  a 
malignant  growth — Clinical  examination — Microscopic  diag- 
nosis      21 

CHAPTER  IV 

The   Destruction   of   Malignant   Growths   by   the   Local 
Cataphoric  Diffusion  of  jMetallic  Ions 

Cancer  a  curable  disease  in  early  stages — Difficulties  attending 
removal — Value  of  author's  method — How  the  method  was 
discovered — Reserve  necessary  in  estimating  actuality  of  cure       30 


vi  Contents. 

CHAPTER  V 

The  Physics  of  the  Ionic  Sterilization  Process,  as  Em- 
ployed IN  THE  Devitalization  of  Disease  Areas 

PAGE 

Electrolysis — Phoresis — Experimental   demonstration  of  mer- 
cury diffusion  within  flesh.  . ' 40 


CHAPTER  VI 

Selection  and  Installation  of  Apparatus  Required  for 
Ionic  Surgery 

Source  of  current — Direct  current  mains — Alternating  current 
mains — Dry  cells — Control  of  current — Measurement  of  cur- 
rent— The  Ionization  Table — Dispersing  pad — Active  elec- 
trodes— Insulation  of  electrodes — Amalgamation — Arrange- 
ment of  portable   apparatus 


CHAPTER  VII 

Operative  Details  of  Ionic  Applications 

Major  monopolar  operation — Maximum  currents  safely  ap- 
plied by  it — Major  bipolar  operation — After  care  of  patients 
— The  minor  application — After  observation — Post-operative 
radiotherapy  and  phototherapy /S 


CHAPTER  VIII 

Concerning  the  Choice  of  Method  in  the  Treatment  of 
Malignant  Growths  in  Various  Situations  and  Stages 

Indications  governing  the  choice  between  ionization  and  other 
methods — Comparative  advantages  of  ionization — Comparative 
disadvantages  of  ionization — Conclusions  as  to  choice  of 
method — Choice  of  major  or  minor  ionic  methods     .       .       .       gi 


CHAPTER  IX 

Applications  to  the  Face  . 


Contents.  vii 

CHAPTER  X 

PAGE 

Applications  within   the  Mouth   and  Nose   ....     138 

CHAPTER  XI 
Applications  to  the  Lips I74 

CHAPTER  Xn 
Applications   to  the   Breast 180 

CHAPTER  Xni 
Applications  to  the  Cervix  Uteri .     199 

CHAPTER  XIV 
Applications  to  the  Rectal  and  Anal  Regions       .       .       .     208 

CHAPTER  XV 

Miscellaneous    Cases    of    Malignant    Disease    in    which 
Zinc-Mercury  Ionization   Was  Used 226 

CHAPTER  XVI 

Surgical    Ionization    in    Accessible    Tubercular^  Deposits 
AND  IN  Hemorrhoids 234 


LIST  OF  ILLUSTRATIONS. 

FIG.  PAGE 

1.  Diagram   of   Monopolar   Ionic   Operation  in   Cancer   of  the 

Breast 34 

2.  Motor-Transformer    of    Holtzer-Cabot    Type    Suitable    for 

Ionic    Surger}' 47 

3.  Diagram  of  Connections  on  Dynamo  of  Motor-Transformer  48 

4.  Portable   Dry-cell    Battery   with    Switchboard    ....  49 

5.  Portable  Dry-cell  Battery  with  Switchboard  Raised  ...  50 

6.  Pocket  Ammeter 51 

7.  Massey  Universal  Graphite  Controller   ....       .       .       .  52 

8.  Plan  of  Wiring  of  Graphite  Controller 53 

9.  Diagram  of  the  Several  Paths  or  Shunts  of  a  Controller  .  54 

10.  Massey   Type    of   Weston    Meter 55 

11.  Ionization  Table 57 

12.  Rear  View  of  Ionization  Table 59 

13.  Kaolin    Pads 61 

14.  Copper  Sterilizer  for  Kaolin  Pads 62 

15.  Author's  Zinc-mercury  Cancer  Electrodes    .       .       .       .       .67 

16.  Major  Spade-shaped  Uterine  Electrode,  Insulated    ...  69 

17.  Diagram  of  Arrangement  of  Portable  Apparatus    ...  71 

18.  Diagram   of  Zones   in   Bipolar   Operation 78 

19.  Diagram  of  Plate  Zinc  employed  as  Bipolar  Negative  Elec- 

trode         79 

20.  Negative  Bipolar  Electrode  for  External  Situations  ...  80 

21.  Case  No.  50  Before  Treatment 102 

22.  Case  28  Before  Treatment 104 

23.  Case  28  Nine  Months  after  Treatment 104 

24.  Case  93  Before  Treatment 105 

25.  Case  93.    Appearance  Four  and  One-half  Years  After  Treat- 

ment          105 

26.  Case  234  Before  Treatment 108 

27.  Case  234  After  Treatment 109 

28.  Case  307  Before  Treatment no 

29.  Case  307  After  One  Bipolar  Treatment in 

30.  Case  347  Before  Treatment 112 

31.  Case   347    After    One    ^Major   Application 113 

32.  Case  347  After  Separation  of  Bone  and  Final  Healing  .        .  113 

33.  Case   364    Before    Treatment 114 

34.  Case  364  After  One  Dispensary'  Treatment 114 

35.  Case  354  Before  Treatment 116 

36.  Case  354  as  Scar  Appears  Three  Years  Later   ....  117 

37.  Case  420  Before  Treatment .       .  118 

ix 


X  List  of  illustrations. 

FIG.  PAGE 

38.  Case  420  Four  Months  Later 119 

39.  Case  529  Before  Treatment 122 

40.  Case  529  Four  Months  Later 123 

41.  Case  89  Before  Treatment 126 

42.  Case  89  One  Year  and  Four  ^Months  Later       ....  126 

43.  Case  653  Before  Treatment 128 

44.  Patient  shown  in  Fig.  43  Five  Days  Later 129 

45.  Patient  Shown  in  Fig.  43'  as  Part  Appears  2  Years  Later  .  129 

46.  Endothelioma  of  E3'elids  Before  Treatment       ....  130 

47.  Endothelioma  of  Eyelids  One  Year  After  Treatment   .  131 

48.  Epithelioma  of  Face  Before  Ionic  Treatment,  Case  763  .        .  132 

49.  Case  763  One  and  a  Half  Years  After  Treatment  .        .       -  I33 

50.  Carcinoma  of  Face  Before  Ionic  Treatment,  Case  765   .       .  134 

51.  Case   765    as    Part   Appears    One   and   a   Half    Years   After 

Treatment - I35 

52.  Epithelioma  of  Face  Before  Treatment,  Case  855    .        .        .  136 

33.     Case  855  One  Year  After  Treatment 136 

53a.  Author's  Ionization  Table,  as  Made  by  Victor  Electric  Co.   .  139 

54.  Case  183  Showing  Outline  of  Lower  Jaw  Four  Years  After 

Operation 150 

55.  Photograph  of  Tongue  Scar  as  It  Appears  Three  and  a  Half 

Years  After  Treatment 152 

56.  Deformity  After  Ionic  Destruction  of  Lower  Jaw   .       .        .  156 

57.  Case  460   as    ]Mouth   Appears   Three   Years    After   Destruc- 

tion of  Epithelioma 158 

58.  Case  830  After  Separation  of   Slough,   Sixteen  Days   After 

Operation 166 

59.  Case   830    Showing    Appearance    of    Scar    One    Year    After 

Operation 167 

60.  Case  697.    Horny  Growth  on  Lip,  with  Epithelioma  of  Mouth  168 

61.  Case  697.    Scar  One  and  a  Half  Years  After  Operation  .        .  169 

62.  Epithelioma  of  Lower  Lip,   Case  609 1/6 

63.  Case  609  Two  Years  and  Four  ]\Ionths  After  Ionic  Operation  177 

64.  Epithelioma  of  Lip,  Case  647 178 

65.  Appearance    of    Lip    in    Case   647    Two    Years    After    Ionic 

Operation 1/8 

66.  Photograph  of  Scars  in  Breast  and  Axilla  Four  Years  After 

Operation 189 

67.  Photograph  of  Wound  After  Separation  of  Slough,  Case  676  196 

68.  Photograph  of  Case  676  After  Complete  Healing   .       .        .197 

69.  Diagram  of  Median  Section  of  Pelvis  Showing  Sarcoma  of 

Sacrum 216 

70.  Sarcoma    Tissue  and  Coccj'x  After  Separation  ....  218 

71.  Photograph  of  Scar  of  Sarcoma  of  Sacrum  Six  Years  After 
Operation 219 

L^-mphoma  of  Xeck 226 


72. 


7S.    Photograph  of  Patient  Shown  in  Fig.  72  Four  Years  Later  .     227 
74.     Sarcoma  of  Neck,  Case  320 228 


List  of  Illustrations.  xi 

FIG.  PAGE 

75.  Appearance  of   Scar  in   Case  320  Three  and  a   Half  Years 

Later 228 

76.  Sarcoma   of    Arm,    Case    474 229 

77.  Scar   of    Sarcoma    of    Arm,    Case   474,    Three   Years    After 

Treatment 229 

78.  Carcinoma  of  Vulva,  Case  772 230 

79.  Scar    of    Case    772    One    and    a    Half    Years    After    Ionic 

Operation 231 

80.  Hard-rubber  Rectal   Speculum,   with    Spiral   Fenestrations    .  238 


PLATES. 

I.     Pope-Massey  Special  Wall  Plate,  Frank  S.  Betz  Co.     .       .       63 
n.     Author's   Ionic    Switchboard,   as   made  by   Williams,    Brown 

&    Earle 65 


INTRODUCTORY. 

That  the  terrible  scourge  of  humanity  embraced  in  the  vari- 
ous malignant  affections  commonly  called  cancer  demands  our 
earnest  attention,  as  a  profession  and  as  a  people,  needs  no 
emphasis  when  the  figures  showing  its  increase  in  civilized 
lands  are  considered.  The  double  showing  of  recently  estab- 
lished facts,  which  indicate  that  cancerous  diseases  are  on  the 
increase  and  that  they  are  primarily  local,  places  an  immense 
responsibility  on  the  members  of  the  medical  profession,  who 
can  no  longer  fold  their  hands  with  honest  sorrow  on  the  dis- 
covery that  a  valued  life  is  threatened  by  a  malignant  growth. 
Their  sorrow  cannot  be  entirely  free  from  a  sense  of  unful- 
filled duty  if  it  has  been  in  their  power  to  remove  the  disease 
soon  after  its  inception ;  and  if  this  may  not  have  been  in  their 
power  by  reason  of  the  ignorance  or  inattention  of  the  patient, 
who  for  these  reasons  failed  to  seek  aid  in  time,  the  respon- 
sibihty  of  the  medical  profession,  as  a  whole,  still  remains,  for  it 
is  the  duty  of  educated  physicians  to  correct  the  popular  im- 
pression that  cancer  is  a  hopeless  disease  from  its  inception  in 
the  great  majority  of  cases.  Indeed,  in  view  of  recent  legis- 
lation in  the  interest  of  public  t^ealth,  it  would  seem  appropriate 
that  the  attention  of  the  various  state  legislatures  be  called  to 
this  subject  in  order  that  proper  measures  be  adopted  to  arrest 
an  apparently  endemic  affection  so  greatly  on  the  increase  as 
to  be  rivaled  by  but  three  other  maladies  as  a  destroyer  of 
mankind — an  affection,  indeed,  that  is  even  more  fatal  than 
tuberculosis  in  its  inroads  on  the  adult  population.  But, 
whether  the  aid  of  the  authorities  in  stamping  out  this  disease 
can  be  properly  secured  at  present  or  not,  the  most  powerful  in- 
strumentality in  attaining  this  end  will  remain  in  the  medical 
profession,  which  should  educate  its  patients  and  the  public  to 
the  point  that  would  lead  to  the  early  destruction  of  all  suspicious 
growths.  That  physicians  who  tell  their  patients  "Don't  touch 
a  cancer  until  you  have  to"  are  more  than  derelict  in  this  duty 
is  evident.  Nothing  better  can  be  expected  until  a  higher  sense 
of  responsibility  leads  to  a  closer  acquaintance  with  the  modern 
facts  involved  in  the  formulation  of  an  opinion.     Until  then  we 


xiv  Introductory. 

shall  continue  to  see  a  host  of  incurable  patients  who  were  not 
urged  to  seek  early  relief,  and  the  knife,  as  well  as  newer,  and 
it  is  to  be  hoped,  better  methods,  will  be  sought  only  when  it 
is  too  late. 

This  hopeless  attitude  towards  cancer  is  largely  due  to  in- 
correct views  of  its  nature,  and  to  incorrect  views  of  the  im- 
portance of  heredity  in  its  prevalence.  The  old  idea  that  its 
local  manifestations  were  the  "pointings"  of  a  constitutional 
disease  was  never  really  held  by  those  who  were  in  the  best 
position  to  know  anything  of  the  matter,  and  it  is  high  time  that 
the  impression  that  this  is  so  be  definitely  displaced  by  the 
teaching  of  scientific  facts  in  favor  of  the  view  that  the  disease 
is  a  primarily  local  foreign  invasion.  To  complete  this  impor- 
tant change  in  the  popular  conception  of  the  disease  it  is 
necessary  that  statisticians  also  recognize  these  facts  and  no 
longer  class  cancer  among  the  constitutional  diseases,  as  now 
generally  done. 

Concerning  heredity,  we  are  now  in  a  position  to  deny  that 
cancer  is  actually  transmitted  by  inheritance,  even  in  cases 
occurring  in  infants  and  clearly  congenital,  for,  like  the  instances 
to  be  found  in  this  work,  these  children  are  born  of  parents 
showing  no  sign  of  the  disease.  The  greater  prevalence  of 
cancer  in  certain  families  apparently  means  merely  that  these 
families  inherit  a  type  of  cell  structure  that  presents  less  re- 
sistance to  the  implantation  of  the  germ.  It  follows  from  this 
that  a  person  who  springs  from  a  family  in  which  a  number  of 
cases  has  occurred  is  not  necessarily  doomed  to  the  same  ex- 
perience, but  merely  possesses  a  constitution  which  demands 
that  greater  care  be  observed  in  the  maintenance  of  robust 
health,  and  a  constitution  that  exacts  greater  vigilance  in  the 
early  recognition  and  prompt  destruction  of  suspicious  growths. 
With  proper  attention  to  these  two  factors  of  prevention,  there 
is  no  reason  why  an  individual  with  this  family  history  should 
not  secure  greater  exemption  from  malignant  disease  than  the 
general  public,  even  in  the  present  state  of  our  knowledge  of  the 
'  causation  of  the  affection.  It  is  quite  possible,  even,  that  some 
of  these  instances  of  successive  infections  in  the  same  family 
may  not  be  due  to  a  less-than-average  immunity  but  to  an  ex- 
posure to  the  same  source  of  infection,  whatever  that  may  be. 

In  spite,  therefore,  of  our  still  incomplete  knowledge  of  cer- 
tain important  scientific  relations  of  the  cancer  cell,  it  is  utter 


Introductory.  xv 

folly  to  allude  to  the  subject  of  cancer  as  still  a  terra  incognita. 
As  a  profession  and  as  a  people  we  know  far  more  about  can- 
cer than  we  act  upon.  We  know,  with  absolute  certainty,  that 
cancer  begins  as  a  purely  local  growth,  with  at  this  time  only 
such  relation  to  the  rest  of  the  body  as  is  involved  in  the 
probable  susceptibility  to  the  implantation  or  development  of 
this  local  growth.  Destroy  or  remove  this  local  growth  in 
this  stage,  and  the  remainder  of  the  body  will  be  as  free  from 
the  disease  as  if  it  had  never  been  present. 

The  prevalent  attitude  of  many  well-meaning  physicians  who 
practically  fold  their  hands  and  wait  for  the  discovery  of  some 
wonderful  antitoxin  to  help  the  vital  forces  to  throw  off  this 
disease  is  as  sensible  as  would  be  the  conduct  of  a  gardener 
who  allowed  weeds  to  grow  in  his  garden  while  experimenting 
with  substances  to  render  the  soil  inimical  to  them.  The  gar- 
dens worked  on  this  plan  would  make  a  sad  showing  alongside 
those  in  the  hands  of  practical  men,  who  destroyed  the  invaders 
at  their  first  appearance. 

It  is  probable  that  the  human  body  will  be  kept  free  from  the 
virulent  weeds  or  animal  organisms  of  the  cancerous  affec- 
tions by  a  similar  system  of  early  eradication  for  years  to 
come;  and  that,  as  our  specific  knowledge  of  its  nature  in- 
creases, the  only  hope  of  a  broader  relief  from  the  disease  lies 
in  the  line  of  prevention. 


IONIC  SURGERY  IN  THE  TREATMENT 
OF  CANCER. 

CHAPTER  I. 

THE    NATURE   OF    MALIGNANT    GROWTHS. 

A  malignant  growth,  like  all  true  tumors,  reveals  on  micro- 
scopic investigation  a  structure  in  which  the  protoplasmic  bits 
of  life  known  as  cells  are  the  chief  feature.  All  tumor  tissues 
share  with  the  general  body  structures  in  the  essential  char- 
acteristic of  being  composed  of  a  collection  of  individual  cell 
entities,  each  cell  being  possessed  of  a  quasi-independent  ex- 
istence under  the  general  correlating  government  of  the 
nervous  system.  Some  of  these  cell  entities  of  the  normal  body 
possess  the  power  of  independent  locomotion  even,  as,  for  in- 
stance, the  leucocytes,  and  in  many  respects  resemble  the 
single-celled  animals,  the  amebae,  which,  composed  only  of  a 
formless  mass  of  nucleated  protoplasm,  lead  an  active  and 
apparently  independent  existence  in  their  normal  habitat. 

Special  cancer  cells  have  been  described,  but  the  most  recent 
consensus  of  pathologists  is  to  the  effect  that  the  cells  of  most, 
at  least,  of  cancerous  growths  do  not  differ  in  shape  from  the 
cells  of  normal  tissues.  The  principal  difference  is  in  their 
position  with  reference  to  the  other  structures  or  stroma  when 
in  their  normal  habitat,  or  to  their  being  outside  their  normal 
habitat,  or  heterotopic.  In  other  words,  the  ordinary  micro- 
scopic evidence  of  malignancy  that  is  most  conclusive  is  that 
which  shows  an  erosion  of  surrounding  structures  by  invading 
cell  masses  in  more  or  less  excess. 

The  histologic  characteristics  of  malignancy  are  therefore 
closely  analogous  to  the  clinical  characteristics,  and  indicate 
that  malignancy  is  evidenced  by  the  excessive  reproduction  of 
cells  which  erode  surrounding  structures  or  organs,  destroying 
them  and  replacing  them  with  their  own  progeny  in  a  mob-like 
aggregation.  The  later  clinical  evidences  of  malignancy  are  a 
natural  extension  of  the  histologic  changes  into  macroscopic 
proportions,  showing  to  the  ordinary  senses  a  progressive,  usu- 


2  The  Nature  of  Malignant  Grozvths. 

ally  painless,  growth  of  the  aggregation,  which  tends  to  de- 
stroy, more  or  less  rapidly,  the  life  of  the  host  by  the  develop- 
ment of  toxins,  but  also  more  especially  by  the  development  of 
intravascular  thrombi  which  are  mechanically  washed  to  more 
vital  organs  in  which  they  form  secondary  erosive  growths 
that  terminate  life. 

The  conditions  involved  in  these  characteristics  of  erosion, 
so-called  metastasis,  and  rapid  growth,  are  therefore  the  dis- 
tinguishing points  between  malignant  and  benign  tumors,  and 
constitute  an  illimitable  chasm  between  them.  In  accordance 
with  these  facts  it  will  invariably  be  found ,  that  a  benign 
tumor  possesses  a  capsule  made  up  of  condensed  surrounding 
tissues  or  other  limiting  membrane,  distinctly  separating  it 
from  contiguous  structures,  and  that  it  can  only  displace  the 
latter  by  pressing  them  aside;  it  cannot  give  rise  to  similar 
tumors  in  the  same  person  by  autoinfection ;  and  it  is  of  rela- 
tively slow  growth. 

Classification. — A  convenient  classification  for  tumors,  in- 
cluding malignant  growths,  has  been  arranged  by  referring  all 
tumors  into  the  same  group  which  are  derived  from  the  same 
germinal  layer  of  the  embryo.  Those  cancers  arising  in  tissues 
derived  from  the  epiblast  and  hypoblast,  the  epithelial  and 
dandular    structures,    are    therefore    classed    as    carcinomas, 

o 

while  those  derived  from  the  mesoblast,  the  connective  tissue 
type,  are  classed  as  sarcomas. 

The  following  arrangement  of  malignant  tumors  has  been 
adapted  from  the  classifications  of  the  most  recent  writers  on 
the  subject: 

CLASSIFICATION  OF  MALIGNANT  TUMORS. 

Histogenetic  Situation  Group  Chief  Varieties 

f  Rodent  cancer   (epithelioma^ 

Epiblastic  and  hypoblastic  )  _  ]       of  the  short-hair  follicles) 

tissues,   producing   Epi-  ,-    Carcinoma  i   Squamous-celled    carcinoma. 

thelial  type.  ;  I   Cylindrical-celled  carcinoma. 

I  Glandular  carcinoma 

I'  Round-celled  sarcoma 
,,,,..  ,  I    Spindle-celled  sarcoma 

Mesoblastic    tissues,    pro-  Lvmpho-sarcoma 

ducmg      Connective-tis-    -    Sarcoma.      <,   ^jVeloid  sarcoma 
sue  type.  )  I   Myxoma 

I  Melano-sarcoma 

To  get  a  clear  comprehension  of  this  classification  of  malig- 
nant tumors  it  should  be  remembered  that  carcinoma  is  prop- 


Classification  of  Malignant  Groivths.  3 

erly  the  name  of  a  group,  of  which  epithelioma,  etc.,  are  varie- 
ties ;  and  that  this  group  includes  the  only  varieties  to  which  the 
name  "cancer"  is  strictly  apphed,  the  several  varieties  of 
sarcoma  not  being  included.  This  restriction  of  the  designa- 
tion to  carcinomas  alone  in  exact  phraseology  has  given  rise  to 
the  general  impression  among  some  physicians  that  sarcomas 
do  not  possess  the  same  degree  of  virulence  as  carcinomas — 
an  impression  that  is  often  greatly  at  variance  with  the  facts. 
The  truth  is  that  this  classification  should  convey  no  such  im- 
pression, for  it  serves  only  for  purposes  of  identification.  The 
classification  is,  in  fact,  somewhat  artificial,  like  the  Linnean 
classification  of  plants  by  botanists,  which  places  the  potato  and 
the  deadly  nightshade  in  the  same  family.  The  carcinoma 
group  includes  genera  and  species  of  every  degree  of  virulence, 
as  does  also  the  sarcoma  group.  The  words  "cancer"  and  "can- 
cerous" might  well  apply  to  the  more  virulent  members  of  each 
group,  and  are  so  employed  when  speaking  comprehensively  of 
malignant  affections  in  this  work. 

Carcinomas  are  cancers  that  arise  primarily  in  situations 
where  epithelial  cells  are  normally  found.  Sarcomas  are  can- 
cerous processes  arising  primarily  in  the  connective  tissues. 
The  degrees  of  virulence  of  the  several  varieties  of  each  group 
are  extremely  variable,  and  this  peculiarity  of  a  given  variety 
has  no  real  relation  to  the  embronal  layer  in  which  it  has  its 
origin.  What  is  probably  the  true  reason  for  the  degree  of 
virulence  possessed  by  each  genus  will  be  referred  to  later. 

One  of  the  most  important  characteristics  of  malignant 
growths  is  the  formation  of  daughter  tumors  by  a  process  of 
colonization,  either  in  contiguous  or  remote  parts  of  the  body, 
this  process  being  accomplished  by  the  entrance  of  the  cells  of 
the  mother  tumor  into  eroded  lymphatics  or  blood  vessels  and 
their  conveyance  therein  to  the  secondary  sites  of  growth. 
These  daughter  tumors  are  said  to  be  invariably  composed  of 
cells  resembling  those  of  the  mother  tumor.  For  instance,  if 
the  primary  tumor  arises  in  the  glandular  cells  of  the  breast  the 
daughter  tumor  will  show  exactly  similar  cells,  somewhat  sim- 
ilarly arranged,  even  if  situated  in  the  liver  or  kidney ;  the  cells 
of  a  tumor  of  the  rectum  will  be  faithfully  reproduced  in  its 
daughter  tumors  in  the  spleen,  etc. 

Moreover,  a  primarily  malignant  tumor  always  grows  by  the 
reproduction  of  cells  of  its  own  kind,  destroying  neighboring 


4  The  Nature  of  Malignant  GroivtJis. 

tissues  and  organs  at  its  periphery  by  an  erosive  process,  and 
replacing  the  cells  normal  to  the  part  by  its  own  special  variety. 
A  carcinoma  may  therefore  extend  far  beyond  the  tissues  de- 
rived from  the  epiblastic  or  hypoblastic  layers  in  which  it  had 
its  origin,  replacing  the  connective  tissue  cells  by  its  own  con- 
quering progeny ;  and  th^  same  is  true  of  a  sarcoma,  which, 
though  necessarily  arising  in  connective  tissues,  may  invade 
tissues  derived  from  any  germinal  layer  when  highly  malignant. 

Xature  of  the  Cancerous  Process. — AMiat,  then,  is  the 
true  nature  of  the  cancerous  process?  The  answer  to  this 
question,  it  is  believed  by  the  author,  can  be  determined  by  the 
clinical  evidence  as  necessarily  parasitic;  and  this  deduction  is 
in  a  fair  way  to  be  proven  by  culture  experiments,  if  not  already 
proven.  Before  reciting  the  circumstances  leading  to  this 
conclusion,  it  is  best  to  briefly  review  the  older  theory  of  the 
nature  of  cancer,  which  is  yet  maintained  by  some  writers  on 
the  subject. 

The  Aijtocytic  Theory. — This  theory,  which  ascribes  the 
cancer  process  to  a  reversion  of  certain  cells  to  their  primitive 
amebiform  condition  after  having  thrown  oft  the  control  of  the 
nervous  system,  is  thus  explained  by  Dr.  Herbert  Snow,  who 
still  adheres  to  it  as  the  best  working  hypothesis.* 

"  The  human  body  is  wholly  composed  of  cells,  pure  and 
simple ;  of  modified  cells ;  and  of  products  formed  within  cells. 
Its  complex  machinery  has  been  built  up  from  a  single  cell  as 
the  starting  point. 

"  The  ameba  is  a  tiny  animal  which  maintains  an  independent 
existence,  and  yet  consists  of  but  a  solitary  cell.  It  is  com- 
posed of  a  jelly-like  substance,  entitled  protoplasm,  anent  whose 
properties  we  practically  know  nothing.  If  we  did,  we  should 
go  far  towards  solving  the  mystery  of  life.  A  small  portion 
of  this  protoplasm,  the  nucleus,  is  differentiated  from  the  rest, 
it  has  higher  vital  and  different  chemical  properties,  and  acts  as 
a  governing  center  to  the  whole.  Some  individuals,  but  not  all, 
have  a  further  differentiation  of  ecto-sarc  and  endo-sarc — that 
is,  of  cell-wall  compact,  and  of  cell-contents  more  fluid. 

"  The  ameba  exhibits  on  a  microscopic  scale  all  the  phenom- 
ena shown  by  the  largest  member  of  the  animal  kingdom.  It 
takes  food  into  its  substance,  digests  it,  excretes  the  useless  por- 

* "  Cancerous  and  Other  Tumors."  B\^  Herbert  Snow,  }iI.D. 
(Lond.)     Bailliere,  Tindall  &  Cox.  London,   1898. 


Nature  of  tlie  Cancerous  Process.  5 

tions.  It  moves  about  by  contracting  and  extending  its  body, 
these  motions  responding  to  excitation  from  without  and  to  im- 
pulse from  within.  It  reproduces  by  fissiparous  division,  com- 
mencing, as  a  rule,  in  the  nucleus.  Lastly,  it  may  be  said  to 
breathe,  the  metabolic  processes  which  nourish  it  being  largely 
processes  of  oxidation. 

"  All  cells  are  fundamentally  constructed  upon  the  same 
ground  plan  as  the  ameba ;  and  all  through  some  part  of  their 
existence  are  practically  distinct  organisms,  moving  in  the  same 
way,  and  leading  a  quasi-independent  life.  The  leucocytes  of 
the  blood  are  from  beginning  to  end  no  more  than  amebse. 

"  The  whole  body  is  evolved  from  clusters  of  ameboid  cells. 
Many  of  these  primordial  organisms  are,  of  course,  eventually 
developed  into  the  various  tissues :  nerve,  muscle,  cartilage, 
bone,  etc. ;  but  many  never  pass  beyond  the  primary  universal 
stage  of  cell-life.  It  is  among  these  or  their  descendants  that 
cancer  arises. 

"  Organization  of  the  cell-clusters  into  formed  tissue  takes 
place  under  the  control  of  the  nerve  centers,  and  by  means  of 
some  regulating  mechanism  inherent  in  the  latter. 

"  Emancipation  from  the  presiding  authority  of  the  central 
nervous  system  during  the  period  of  development  involves 
structural  aberration,  such  as  the  various  deformities  or 
'freaks.' 

"  Weakness  or  derangement  of  the  central  power,  after  the 
organism  has  reached  maturity,  results  first  in  disordered  func- 
tion, i.  e.,  in  ill-health ;  secondly,  and  generally  after  some  con- 
tinuance of  the  former  stage,  in  organic  morbid  changes,  i.  e.,  in 
disease.  It  is  hardly  too  much  to  say  that  all  maladies  not 
directly  induced  by  extraneous  agency  are  primarily  nerve  de- 
rangements." 

After  thus  revicAving  the  principal  facts  of  cellular  physi- 
ology. Dr.  Herbert  Snow  continues  : 

The  autocytic  theory  ascribes  cancer  to  a  reversion  of  the 
natural  cells  or  cell  elements  to  that  primitive  amebiform  con- 
dition from  which  all  have  emerged,  and  in  which  a  few  still 
persist.  Each  cell  then  casts  off  its  allegiance  to  the  nerve 
centers,  which  cease  to  exert  over  it  the  least  control.  It  be- 
comes a  quasi-independent  parasite,  or  rather  autocyte. 

"  The  malignant  or  '  cancer  '  cell  now  preys,  exactly  as  a 
parasite  would,  upon  the  healthy  parts  around,  devouring  these. 


6  The  Nature  of  Malignant  Growths. 

and  appropriating  the  nutriment  destined  for  them.  Its  hfe  is 
not  as  their  Hfe,  and  involves  sooner  or  later  their  death.  Ulti- 
mately it  brings  about  the  somatic  death  of  the  whole  organism. 

"  A  runaway  horse  furnishes  an  apt,  if  homely,  exemplar  of 
cancerous  disease,  as  conceived  by  the  autocytic  theory. 

"The  numerous  species- of  cancer  depend  on  the  particular 
kind  of  cell  subjected  to  this  morbid  reversion,  the  cancer 
process." 

Such  is  a  succinct  statement  of  a  "working  hypothesis"  of 
apparent  importance  in  the  elucidation  of  the  problem  of  the 
true  nature  of  cancer.  It  must  be  admitted  that  it  offers  a  com- 
prehensible explanation  of  the  fact  that  cancer  cells  resemble  the 
cells  of  the  organ  in  which  they  primarily  appear.  Yet  it  is 
hard  to  understand  how  a  simple  release  of  a  given  group  of 
cells  from  nervous  control  could  produce  the  enormous  change 
of  character  involved  in  the  conversion  of  these  useful  bits  of 
protoplasm  into  the  microscopic  ravening  beasts  of  malignancy. 
Such  miraculous  character  transformations  are  scientifically 
inconceivable,  even  admitting  a  full  reversion  to  the  amebiform 
independence  alluded  to,  for  the  physical  basis  of  a  man's  fixed- 
ness of  character  has  been  well  established  by  biologists  as  an 
almost  changeless  product  of  hereditary  traits,  and  what  is  true 
of  the  somatic  individual  must  be  an  even  less  complicated  fact 
of  the  minute  protoplasmic  entities  of  which  he  is  composed. 

If  the  essential  elements  of  cancer  are  the  cells,  which  re- 
semble the  normal  cells  at  the  initial  point  of  development  and 
are  so  faithfully  reproduced  as  to  character  and  grouping  in  dis- 
tant colonies,  there  must  be  some  profound  change  in  their 
character  to  constitute  the  malignancy.  Can  this  profound 
change  (which  may  be  summarized  as  an  added  power  of 
growth  and  new  powers  to  erode  and  colonize)  be  produced  by 
a  mere  withdrawal  from  nervous  influence  ? 

The  Parasitic  Theory. — The  search  for  a  demonstrable 
parasite  that  will  produce  a  cancer  when  inoculated  into  the 
bodies  of  the  lower  animals  or  of  man  is  now  actively  under 
prosecution  by  a  number  of  laboratory  workers  in  America  and 
elsewhere,  and  definite  announcements  of  success  have  recently 
been  made  by  Sanfelice,  in  Italy,  Plimmer,  in  England,  and 
Gaylord,  of  Buffalo,  N.  Y.  Sanfelice  announced  that  a  blasto- 
mycetic  fungus,  like  that  of  the  yeast  plant,  is  the  responsible 
agent  of  the  growth,  while  Plimmer  and  Gaylord  believe  they 


The  Parasitic  Theory.  7 

liave  isolated  and  cultivated  a  protozoon  that  produces  cancer 
growths.  It  is  probable  that  pathologists  themselves  are  not 
yet  in  a  position  to  pass  judgment  on  any  of  the  questions  thus 
propounded.  Mere  students  of  the  literary  contributions  of 
these  investigators  are  further  disheartened  by  a  very  long  list 
of  similar  claims  by  previous  workers  during  the  past  twenty 
years,  many  of  which  failed  to  be  corroborated.  The  careful 
■observer  must,  therefore,  still  keep  his  judgment  in  suspension, 
even  though  he  believes  the  probabilities  all  favor  the  parasitic 
origin  of  these  growths. 

The  difficulties  in  the  way  of  the  investigation  are  indeed 
enormous,  and  almost  unprecedented,  in  comparison  with  other 
work  in  the  artificial  cultivation  of  disease  germs.  Practically 
all  of  the  recent  cultivation  discoveries  in  the  elucidation  of  the 
causation  of  disease  have  been  concerned  with  quickly-growing 
plant  life ;  a  few  days,  or  at  most,  weeks,  being  sufficient  for  the 
development  of  the  disease  within  the  animal  or  in  artificial 
cultures.  In  cancer,  months  or  years  are  required  for  the  de- 
velopment of  the  disease  in  the  human  body,  hence  an  equal 
time  may  be  required  in  artificial  cultures,  with  methods  totally 
different  from  those  employed  in  bacteriolog}^  If  the  germ 
belongs  to  the  animal  kingdom  the  example  of  malaria  at  once 
occurs,  where  no  real  progress  was  made  until  the  extra-human 
portion  of  the  life  cycle  of  the  plasmodium  was  made  plain 
by  the  discovery  of  the  anopheles  mosquito  as  an  essential 
host. 

Clinical  Evidences  that  Cancer  is  Due  to  the  Invasion  of  an 
Extrinsic  Germ. — The  efforts  of  the  practical  physician  to  con- 
trol rnalignant  diseases  need  not,  however,  be  arrested  while 
the  laboratory  workers  are  yet  engaged  in  their  important  re- 
searches. Certain  clinical  evidences  point  so  surely  to  their 
parasitic  nature  that  to  treat  them  otherwise  is  the  extreme  of 
unwisdom.  Many  of  the  well-known  infectious  germ  diseases 
have  been  treated  for  ages  as  parasitic  on  the  strength  of  posi- 
tive clinical  evidences,  yet  their  specific  germs  are  still  undiscov- 
ered. The  absence,  or  extreme  infrequency  of  evidences  of 
infectiousness  has  been  the  chief  bar  to  a  recognition  of  the 
specificity  of  cancer,  yet  our  recently  acquired  knowledge  of 
the  role  of  intermediate  hosts,  and  of  the  longer  life  histories 
and  special  environments  of  protozoal  organisms  may  easily 
account  for  this. 


8  The  Nature  of  Malignant  Growths. 

Some  of  the  clinical  evidences  of  the  parasitic  nature  of  can- 
cer may  be  summarized  as  follows  : 

I.  Erosion,  the  chief  cause  of  malignancy,  is  impossible  of 
explanation  except  by  the  possession  of  a  life  pozver  on  the 
part  of  the  cancer  cell  that  is  independent  of  that  possessed  by 
the  surrounding  normal  cells. — Erosion  means  devouring, 
practically,  when  used  as  descriptive  of  the  method  by  which  a 
malignant  growth  extends  at  its  periphery  into  the  surrounding 
tissues,  and  this  pathologic  process  is  only  found  to  exist  in 
affections  caused  by  extrinsic  or  parasitic  germs.  Benign 
tumors  displace  contiguous  organs  and  structures  by  pressure, 
pushing  aside  the  latter,  while  malignant  tumors  eat  into  and 
destroy  them.  The  malignant  growth  represents  an  irrepres- 
sible conflict  between  a  foreign  and  a  domestic  army;  the 
triumph  of  the  invading  forces  meaning  the  total  destruction 
of  the  defenders  in  the  vicinity  of  the  combat  and  the  re-popu- 
lation of  the  contiguous  territories  by  the  invaders,  with  final 
death  of  the  whole  commonwealth  by  a  combined  process  of 
local  extension  of  the  invasion  and  general  political  poisoning. 
No  truce,  or  peaceful  occupation  of  a  province  from  which  the 
inhabitants  are  driven,  can  occur,  as  happens  in  analogous 
manner  with  benign  tumors,  though  the  enemy  may  be  locally 
checked  and  walled  off,  as  it  were,  in  very  rare  instances.  An 
example  of  the  latter  condition  is  seen  in  the  so-called  stone 
cancers  of  the  breast,  which  are  the  result  of  unusual  vigor  in 
the  phagocytic  connective  tissue  cells,  whose  interlacing  fibrils 
choke  the  malignant  cell  growth.  The  conflict  usually  has  but 
one  ending,  unless  outside  force  is  invoked  to  destroy  the  in- 
vaders. 

2.  Malignant  growths  show,  when  classified,  a  division  into 
related  families,  genera  and  species  similar  to  those  charac- 
teristic of  living  integers  in  both  the  animal  and  vegetable 
kingdoms. — This  classification  is  more  significantly  similar 
also  than  is  usually  supposed.  The  zoological  classification  of 
dogs  and  lions  together  and  cats  and  tigers  is  paralleled  by  the 
inclusion  of  the  spindle-celled  sarcoma  and  melano-sarcoma  in 
the  same  family ;  of  the  rodent  ulcer  and  the  quickly-growing 
epitheliomas ;  of  the  ordinary  acinous  cancer  of  the  breast  and 
the  fulminating  variety.  The  botanical  classification  of  poi- 
sonous and  non-poisonous  plants  in  the  same  family  is  well- 
known,  such  as  tobacco,  belladonna,  the  potato  and  the  tomato 


Clinical  Evidences  of  Germ  Origin.  9 

in  the  order  solanacea ;  the  edible  agaricus  campestris  and  the 
poisonous  amanita  in  the  sub-order  of  mushrooms,  etc. 

3.  The  immutahility  of  species  is  as  marked  a  characteristic 
of  malignant  growths  as  in  any  other  order  of  life.  Like  pro- 
duces like  in  cancers  as  surely  as  in  all  other  living  things, 
whether  of  the  animal  or  vegetable  kingdom. — The  relation  of 
parent  and  progeny  is  not  only  evident  in  the  reproduction  of 
malignant  cells  incident  to  the  growth  and  local  extension  of  a 
cancer,  but,  most  significantly,  in  the  resemblance  between 
parent  colony  and  daughter  colony  in  the  mode  of  extension 
miscalled  metastasis  *  in  which  a  graft  from  a  cancer  of  the 
breast,  for  instance,  when  arrested  in  the  capillaries  of  the  lung, 
liver,  or  elsewhere,  reproduces  cells  resembling  the  mother 
tumor. 

But  this  last  mentioned  clinical  evidence  of  the  parasitic 
nature  of  cancer — the  similarity  between  the  cells  and  their 
arrangement  in  t'he  mother  tumor  and  daughter  tumors — is,  at 
first  sight,  a  stumbling  block  to  the  parasitic  hypothesis,  for 
the  reappearance  of  the  special  type  and  arrangement  of  the 
mammary  cells  in  the  daughter  tumor  seems  to  support  the 
autocytic  theory  of  a  mere  change  in  their  character.  The 
answer  to  this  is  that  the  main  point,  after  all,  is  the  reproduc- 
tion of  this  special  form  of  "changed  character,"  which  is  a 
far  more  significant  phenomenon  than  the  persistence  of  the 
histologic  type.  It  is  probable  that  we  have  two  reproductions 
to  deal  with :  the  reproduction  of  the  cell  of  the  organ  primarily 
infected,  and  the  reproduction  of  the  parasitic  cell-inclusion, 
and  that  the  latter  hereditary  trait  is  by  far  the  most  important. 

It  may  be  tentatively  stated,  therefore,  that  a  cancer  groWs 
and  reproduces  itself  by  the  reproduction  of  cells  which  have 
become  changed  in  character  by  reason  of  the  presence  of 
parasitic  germs,  and  that  each  generation  of  cells  thus  changed 
contains  new  generations  of  the  infecting  germs. 

*  The  word  colonization  describes  the  transference  of  a  portion  of 
a  disease  to  another  place,  without  change  in  the  original  seat  of  the 
disease,  better  than  the  term  metastasis,  which  is  more  strictly  applied 
to  the  disappearance  of  a  condition  at  one  point  and  its  reappearance 
at  another,  as  in  acute  rheumatism. 


CHAPTER  11. 

THE    SEARCH    FOR   POSSIBLE    CAXCER    GERMS. 

Xo  "Quest  of  the  Holy  Grail"'  compares  in  altruistic  value  to 
the  human  race  with  the  labors  of  our  modern  knights  of  the 
laboratory,  who  with  unwearied  patience  must  question  all 
things  of  the  earth,  air,  and  waters  beneath  for  the  germs  them- 
selves or  their  possible  hosts  in  living  plants  or  vegetables,  from 
contact  with  which  susceptible  persons  may  be  infected.  The 
old  theor}-  of  the  tomato  having  an  etiologic  connection  with 
cancer  is  suggestive  but  may  tentatively  be  dismissed  as  im- 
probable. Sanfelice,  of  Italy,  announced  several  years  ago  that 
he  had  discovered  the  germ  in  a  blastomycetic  fungus,  that 
others  later  found  in  the  yeast-like  rust  of  lemons,  and  Gaylord 
still  later  investigated  the  tumors  on  certain  cabbage  roots.  A 
fruitful  field  for  further  research  is  indicated  in  these  direc- 
tions, and  the  research  should  include  the  many  forms  of 
distorted  vegetable  cells  found  in  diseased  corn,  rye,  and  the 
so-called  cancerous  tumors  of  trees. 

Alfred  Haviland,  of  England,  has  made  an  inquiry  into  the 
geologic  surface  formations  of  various  portions  of  the  British 
Isles  with  reference  to  the  distribution  of  cancer,  and  has 
embodied  the  results  in  several  w^orks  and  journal  articles 
showing  that  cancer  is  more  prevalent  in  wooded  river  valleys 
with  clay  subsoil,  in  which  the  rivers  occasionally  overflow 
their  banks.  These  conclusions  have  been  rejected  by  others, 
who  point  out  that  the  river  valleys  mentioned  were  the  seat  of 
large  towns  containing  infirmaries  and  hospitals  to  which  pa- 
tients were  attracted,  thus  artificially  swelling  the  mortality 
statistics.  In  a  more  recent  paper  published  in  the  Practitioner 
for  April,  1899,  a  closer  study  of  the  question  is  made,  small 
districts  being  compared  with  each  other  in  which  large  hos- 
pitals did  not  exist,  and  the  conclusion  was  distinctly  evident 
that  the  limestone  districts  presented  the  lowest  mortality  from 
cancer,  while  flooded  clays  presented  the  highest. 

Mode  of  Infection. — The  method  by  which  the  parasite  gains 


Evidences  of  Infectivity.  ii 

entrance  into  the  body  is  as  dark  a  secret  as  its  external 
habitat.  That  it  may  be  contracted  by  one  person  from  an- 
other is  evidenced  by  several  well-authenticated  instances, 
reported  by  Kuhn,  Hyatt,  Gross,  and  Budd.  Gnelliott  has, 
according  to  Park,  collected  twenty-eight  cases  of  transmission 
to  husbands  of  cancer  from  their  wives,  and  it  is. said  that  at 
least  five  French  hospital  surgeons  have  died  from  cancer — 
presumably  acquired  in  the  practice  of  their  profession. 

Against  the  theory  of  direct  contagion  may  be  cited  the 
general  experience  of  physicians  and  surgeons  brought  in  con- 
tact with  numberless  cases  of  the  disease,  which  practically 
negatives  the  possibility  of  this  method  being  the  usual  one  in 
which  cancer  is  acquired. 

That  the  parasite  may  gain  entrance  into  the  body  through 
the  natural  channels  is  indicated  by  the  greater  prevalence  of 
carcinomas  at  or  near  the  natural  openings,  as  in  the  lips, 
mouth,  throat,  stomach,  nipples,  cervix  uteri,  and  rectum. 

The  effect  of  irritation  in  preparing  a  nidus  for  the  parasite 
is  generally  conceded :  as  bad  teeth  or  unwholesome  gums, 
continuous  cigar  smoking,  and  the  presence  of  scars  and  in- 
flammatory irritations  within  the  cervix  uteri  and  rectum.  On 
the  other  hand,  J.  M.  Fadgean  points  out  that  cancer  of  the 
penis  in  horses  occurred  in  geldings,  not  stallions ;  that  car- 
cinoma is  rare  in  the  udders  of  milch  cows  notwithstanding 
the  handling  and  irritation  these  organs  are  subjected  to  in 
these  animals ;  and  that  of  thirty-one  cases  of  carcinoma  in  the 
horse  not  one  had  the  starting  point  in  any  of  those  parts  of  the 
animal  which  are  specially  exposed  to  the  irritation  of  friction 
by  the  harness  or  otherwise. 

The  possibility  of  cancer  parasites  infecting  houses  and  thence 
propagating  themselves  within  the  tissues  of  successive  resi- 
dents, somewhat  as  Flick  has  demonstrated  in  Philadelphia  in 
the  case  of  tuberculosis,  has  been  recently  pointed  out  by  sev- 
eral writers.  Behla*  reports  seventy-three  deaths  from  cancer 
in  the  small  town  of  Luckau  during  twenty-three  years,  all 
within  an  area  no  larger  than  two  or  three  city  squares,  as 
many  as  four  deaths  occurring  in  one  house.  D'Arcy  Power's 
maps  of  a  "cancer  field"  in  the  number  of  the  Practitioner 
referred  to  are  most  suggestive,  showing  the  grouping  of  the 
cases  in  the  houses  of  a  certain  district  in  England,  where  the 
*  Centralblatt   fiir  Bakteriologie,   Nos.  21   to  24,   1898. 


12  The  Search  for  Cancer  Germs. 

geologic  conditions  found  by  Haviland  to  favor  cancer — a 
clay  soil  and  numerous  sluggish  water  courses — were  typically 
present.  In  one  of  these  houses  three  deaths  from  malignant 
disease  occurred  successively  among  persons  not  related,  and 
in  the  paper  a  number  of  similar  instances  are  given.  The 
most  remarkable  instance  is,  however,  the  localization  of  a  series 
of  three  cases  of  unrelated  persons  in  a  single  room.  The 
account  given  of  these  cases  is  as  follows : 

Miss  B.,  aged  forty-five,  lived  in  a  certain  house  in  a  suburb 
of  London  for  thirteen  years,  and  died  of  cancer  of  the  stomach 
in  1884.  Miss  T.,  aged  forty-seven,  then  succeeded  to  her 
place  and  occupied  her  bedroom.  She  had  lived  in  the  house 
for  twenty  years,  and  died  of  cancer  of  the  liver  in  October, 
1885.  Mrs.  J.,  aged  sixty-seven,  who  had  lived  in  the  house 
for  eight  years,  succeeded  to  the  place  and  bedroom  successively 
occupied  by  Miss  B.  and  by  Miss  T.  Mrs.  J.  died  of  cancer 
of  the  breast  and  uterus  in  1893.  Each  of  these  patients  ap- 
peared to  be  in  perfect  health  until  they  took  one  another's 
place  as  housekeeper  to  the  barmaids  of  the  establishment  in 
which  they  had  lived  so  long  a  time.  There  was  no  blood 
relationship  between  them.  One  of  the  sons  of  the  house,  who 
is  a  nephew  of  Miss  T.,  has  a  keloid  which  has  been  removed 
three  times.  No  further  cases  of  cancer  had  occurred  in  this 
house  since  the  rooms  have  been  disinfected  with  sulphur  and 
the  bedding  burnt. 

But  the  most  apparently  conclusive  evidence  of  the  possibility 
of  the  contact,  or  house,  infection  of  cancer  has  been  presented 
in  the  recently  observed  instances  of  cancer  occurring  as  en- 
demics among  small  animals  confined  in  cages  for  laboratory 
purposes  or  otherwise.  Borrel,  Michaelis,  and  Loeb  have  con- 
tributed observations  on  this  point,  but  the  most  interesting  re- 
cent report  on  the  subject  is  that  of  Gaylord  and  Clowes,*  who, 
after  reporting  the  occurrence  of  three  similar  sarcomas  in  rats 
placed  in  a  cage  in  the  New  York  State  Laboratory  at  Buffalo 
from  which  Dr.  Loeb  had  removed  sarcomatous  rats  nearly  two 
years  before,  the  cage  not  having  been  sterilized,  the  rats 
being  unrelated  to  Dr.  Loeb's  rats,  and  no  sarcomas  having 
been  observed  in  one  hundred  rats  in  other  cages  in  the  labora- 
tory under  similar  conditions,  gives  the  following  interesting 
account  of  an  endemic  of  cancer  in  a  certain  cage  of  mice  in 

*  Journal  American  Medical  Association,  January  5,  1907,  p.  15. 


Evidences  of  Infectivity.  13 

the  establishment  of  a  dealer  who  had  been  engaged  in  the 
raising  of  these  animals  for  several  years  in  Springfield,  Ohio : 

"One  of  us  visited  the  establishment  in  question  June  8, 
1906,  in  the  company  of  Dr.  Rand,  of  Springfield,  v^ho  heard 
the  entire  statement  made  by  Mr.  Landes,  the  owner  of  the 
establishment  and  a  man  of  intelligence.  The  statement  which 
he  gave  us  regarding  the  occurrence  of  these  tumors,  many  of 
which  came  under  our  own  personal  observation,  appeared 
to  be  perfectly  logical  and  entirely  free  from  discrepancies. 
In  the  course  of  the  previous  year  Mr.  Landes  had  sent  this 
laboratory  six  white  mice  with  spontaneous  tumors,  which 
proved  on  microscopic  examination  to  be  adenocarcinomata  of 
the  breast.  They  were  all  in  females  and  all  located  on  the 
abdominal  aspect.  We  found  on  inquiry  that  Mr.  Landes 
recognized  the  fact  that  the  source  of  these  tumors  was  one  old 
cage,  built  of  wood,  one  end  of  which  was  screened  off  with 
netting.  He  stated  that  the  cage  was  3  years  old  and  that  it 
had  contained  for  3  years  an  average  of  about  100  old  mice. 
He  estimated  that  these  mice  bred  to  such  an  extent  that  he 
was  able  to  get  between  one  and  two  thousand  young  ones  out 
of  this  cage,  annually. 

^'The  history  of  this  cage  is  as  follows :  It  was  built  in  July, 

1903,  at  his  place  of  business,  which  was  then  at  the  corner  of 
Shafer  and  Columbia  Streets.  2}^  miles  distant  from  its  present 
location.  It  was  kept  in  a  barn,  the  boards  of  which  were 
poorly  matched,  and  the  place  was  cold  and  windy  in  winter. 
It  remained  nearly  a  year  in  this  barn  and  contained  during  this 
period  about  100  mice.  During  the  course  of  the  winter  he 
found  one  or  two  mice  with  tumors  in  the  cage.     In  April, 

1904,  he  moved  to  the  corner  of  Light  and  Cedar  Streets,  two 
or  three  squares  from  the  first  location,  and  the  cage  was  kept 
in  a  large  coal  shed,  which  was  warm  and  comfortable.  It 
remained  from  April  to  November,  1904,  in  this  locality  and 
during  that  period  he  removed  from  the  cage  25  to  30  mice 
with  tumors.  In  November,  1904,  he  moved  to  his  present 
location,  2^  miles  distant  from  the  first  two  mentioned.  Be- 
fore the  cage  was  removed  from  Light  and  Cedar  Streets  he 
observed  12  mice  at  one  time  with  tumors,  and  for  the  purpose 
of  ridding  himself  of  this  unfortunate  development  of  tumors 
he  decided  to  change  entirely  the  stock  in  the  cage.  All  the 
mice  \\^ich  had  occupied  the  cage  were  removed  and  12  adult. 


14  ■       The  Search  for  Cancer  Germs. 

healthy  mice,  lo  females  and  2  males,  were  imported  from 
Washington,  D.  C,  and  introduced  into  the  cage,  which  was 
placed  in  a  small,  detached  outhouse,  at  least  50  feet  distant 
from  the  present  location  of  the  cage.  During  the  course  of 
this  winter  3  or  4  tumors  developed. 

"Since  the  spring  of  1905,  the  cage  has  been  in  a  large  room 
30  by  50  feet  in  size,  which  was  previously  a  dance  hall,  and 
it  now  stands  on  a  table  6  to  7  feet  from  a  window  where  the 
conditions  of  light  and  ventilation  are  excellent.  It  previously 
stood  in  a  different  position  in  the  room  about  20  feet  from  its 
present  location.  During  the  last  year  he  has  removed  between 
25  and  30  mice  with  tumors  from  the  cage,  several  of  which 
have  been  sent  to  us.  Owing  to  a  misunderstanding  on  his 
part  he  had  the  idea  that  only  tumors  between  the  front  legs 
were  what  we  desired,  and  those  which  appeared  on  the  flanks 
or  lateral  aspect  of  the  abdominal  region,  he  killed.  At  the  time 
of  my  visit  one  mouse  was  in  the  cage  with  2  large  tumors 
on  the  right  abdominal  aspect.  He  pointed  this  out  as  an 
example  of  the  kind  of  tumors  which  he  thought  we  did  not 
require.  He  states  that  he  has  never  seen  a  tumor  on  the  back 
of  any  mouse.  He  thinks  they  were  mostly  females,  and  in 
several  instances  when  he  examined  them  as  to  their  sex  he 
found  they  were  females.  He  has  never  seen  a  male  with  a 
tumor.     The  tumors  have  frequently  grown  to  great  size. 

"Besides  the  old  cage,  his  establishment  contains  12  or  15 
other  cages  of  similar  construction.  One  of  these  is  2  years 
old,  the  remainder  i  year  old.  They  are  regularly  stocked 
from  the  old  cage.  His  custom  is  to  remove  from  the  old  cage 
12  or  more  females  with  one  or  two  bucks  and  place  them  in 
the  new  cages  and  allow  them  to  remain  there  until  each  cage 
contains  approximately  100  mice.  The  half  and  three-quarters 
grown  offspring  are  removed  and  sold.  In  the  cage  which  is 
now  2  years  old  he  has  during  the  past  year  observed  4  to  6 
mice  with  tumors.  So  far  no  tumors  have  appeared  in  mic£^in 
the  other  cages  in  the  establishment.  He  remembers  having 
seen  one  or  two  tumor  mice  in  some  of  his  old  cages  in  his 
previous  establishments,  but  these  cages  were  always  stocked 
from  the  old  cage  already  described,  which  seems  to  have  been 
the  source  of  all  his  operations,  and  which  he  referred  to  as 
his  incubator.  The  cage  was  purchased  by  the  laboratory  and 
brought  to   Buffalo   with   the   mice   in   it.     On   reaching   the 


Evidences  of  Infectivity.  15 

laboratory  it  was  found  to  contain  3  mice  with  large  tumors. 
The  interior  of  the  cage  is  dark  and  damp,  incrusted  with 
excreta,  and  presents  a  generally  unhygienic  appearance.  Ex- 
amination on  the  date  of  sending  this  manuscript  for  publica- 
tion, August  3,  shows  that  the  cage  contains  28  adult  and 
perhaps  twice  as  many  half-grown  and  young  mice.  On  the 
floor  of  the  cage  is  the  carcass  of  a  mouse  which  has  apparently 
been  dead  some  hours,  with  a  large  tumor  on  the  abdominal 
aspect.  This  is  ulcerated  and  shows  evidence  of  having  been 
gnawed.  A  second  mouse  with  a  tumor  the  size  of  a  large 
hazelnut  protruding  between  the  hind  legs  and  evidently  spring- 
ing from  the  posterior  part  of  the  mammary  tissue  is  also 
found.  The  skin  over  this  tumor  is  adherent  and  the  tumor 
is  evidently  far  advanced. 

"Briefly  stated,  the  facts  in  the  above  case  are  as  follows : 
A  cage  has  been  discovered  in  which  upwards  of  60  spon- 
taneous tumors  have  occurred  in  the  course  of  3  years.  The 
fact  that  the  location  of  the  cage  was  frequently  changed,  and 
the  stock  entirely  renewed  on  at  least  one  occasion  without 
any  permanent  interference  with  the  production  of  tumors, 
makes  it  apparent  that  the  cage  itself  was  the  source  of  in- 
fection. 

"Besides  these  observations  which  point  directly  to  the  cage 
as  the  source  of  infection,  the  endemic  occurrence  of  cancer 
among  mice  in  breeding  establishments  is  well  known  and  is 
illustrated  to  a  remarkable  degree  in  our  own  experience.  For 
instance,  from  January,  1905,  until  the  present  time,  this  labora- 
tory has  had  a  standing  reward  of  twenty-five  dollars  for  any 
small  animal  affected  with  cancer.  This  offer,  as  already 
stated,  was  sent  to  325  dealers  in  pet  animals.  It  is  possible 
that  many  of  them  have  not  appreciated  the  significance  of  the 
offer,  or  have  ove'rlooked  cases  of  cancer  in  their  stock,  but 
during  this  period  we  have  had  constant  business  relations  with 
seven  dealers  in  different  parts  of  the  country,  from  whom  we 
have  purchased  large  numbers  of  mice,  and  who,  we  feel  per- 
fectly certain,  have  fully  appreciated  the  monetary  value  of 
cancer  mice.  From  one  of  these  dealers  we  have  received  no 
less  than'  eighteen  female  mice  with  cancer  of  the  breast ;  from 
a  second  dealer,  five  of  the  same  nature  and  sex;  from  two 
other  dealers,  one  each,  and  from  three  from  whom  we  have 
had  repeated  shipments  of  mice,  none  whatsoever.     From  one 


i6  The  Search  for  Cancer  Germs. 

of  these  dealers  from  whom  we  have  received  in  the  last  two 
years  not  less  than  1,200  normal  mice,  we  learn  that  he  has 
never,  in  his  own  stock,  seen  an  example  of  cancer  of  the 
mouse,  but  that  he  was  able  to  recognize  the  affection  was 
shown  by  his  having  secured  for  us  from  another  dealer  a 
single  specimen. 

"These  figures  conclusively  indicate  that  in  certain  breeding 
establishments  cancer  in  white  mice  is  endemic.  The  condition 
of  affairs  in  the  breeding  establishment  of  a  dealer  in  Massa- 
chusetts is  interesting  when  compared  with  that  of  the  Spring- 
field dealer,  where  the  evidence  pointed  to  a  single  cage  as  the 
source  of  infection.  This  Massachusetts  dealer  has  shipped  to 
us,  in  all,  eighteen  cancer  mice,  in  lots  of  nine,  four,  and  five, 
and  it  is  of  great  interest  that  the  tumors  in  all  of  these  mice 
were  of  relatively  the  same  size.  On  inquiry  as  to  where  the 
tumors  had  developed,  if  they  could  be  traced  to  a  given  cage 
or  group  of  cages,  we  were  notified  that  the  mice  were  scat- 
tered indiscriminately  through  the  entire  establishment.  This 
condition  of  affairs  was  so  interesting  that  we  made  a  trip  to 
Massachusetts  to  personally  inspect  the  premises,  whereupon 
it  was  found  that  this  dealer,  in  order  to  combat  infectious  and 
contagious  diseases  had  her  stock  distributed  among  a  large 
number  of  small  boxes.  These  mice  were  moved  about  from 
box  to  box  and  the  different  families  were  regularly  subdivided 
and  used  for  the  purpose  of  forming  new  families.  This 
practice  is  entirely  different  from  that  of  the  Springfield  estab- 
lishment and  easily  explains  the  general  distribution  of  the 
tumor  mice  through  the  different  breeding  boxes.  The  fact 
that  the  tumors  have  developed  in  lots  of  half  a  dozen  or  more 
at  one  time  and  that  in  the  various  shipments  to  us  the  tumors 
have  been  of  relatively  the  same  size,  suggest  that  small  epi- 
demics have  occurred  at  frequent  intervals.  The  attempt  to 
trace  the  origin  of  the  infection  to  any  particular  box  in  the 
establishment  is,  of  course,  under  the  present  system,  impos- 
sible, and  it  is  not  improbable  that  this  method  has  led  to  the 
dissemination  of  the  contagion  through  a  large  number  of 
the  boxes. 

"The  foregoing  observations  indicate  that  both  sarcoma  in 
rats  and  carcinoma  of  the  breast  in  mice  must  be  looked  on  as 
contagious,  and  when  considered  in  conjunction  with  the  classi- 
cal observations  of  Loeb  and  Borrel,  in  which,  however,  it 


Local  Dissemination.  17 

was  impossible  entirely  to  exclude  the  factor  of  heredity,  should 
lead  us  to  pay  more  serious  consideration  to  the  interesting 
statistics  constantly  accumulating  which  show  the  probable 
infection  of  the  surroundings  of  human  cancer  cases  in  so- 
called  "cancer  houses."  It  should  also  lead  to  earnest  con- 
sideration of  the  desirability  of  sterilizing  the  dressings  of 
cancer  cases  and  the  complete  sterilization  of  rooms  which  pa- 
tients have  occupied,  and  it  should,  at  least  to  no  inconsider- 
able extent,  offset  the  recent  statement  of  Hansemann,  that  we 
have  no  right  to  add  to  the  difficulties  of  the  cancer  patient  by 
the  unnecessary  suspicion  that  he  is  suffering  from  an  infectious 
■disease.  It  should  tend  to  combat  the  belief  among  patholo- 
gists that  there  are  no  grounds  for  even  suspecting  an  infectious 
factor  in  malignant  tumors." 

LIFE   HISTORY  OF  A  CANCEROUS   GROWTH. 

In  spite  of  our  still  imperfect  knowledge  of  the  source,  inter- 
mediate host  of  germ,  and  mode  of  infection  of  malignant 
■diseases,  we  are  in  possession  of  definite  facts  as  to  the  life 
history  and  clinical  behavior  of  these  affections  from  their 
inception  in  the  human  body  that  are  very  valuable  in  prog- 
nosis and  treatment.  The  most  important  of  these  affirms 
that  all  malignant  diseases  are  strictly  local  in  their  inception 
and  not,  in  this  stage,  in  any  sense  constitutional.  Whatever 
the  nature  of  the  malignant  growth,  it  is  strictly  limited  at  first 
to  the  locality  in  which  it  arises,  and  may  in  this  stage  be 
eradicated  by  destruction  or  removal  of  all  of  the  infected  cells. 
If  this  be  neglected,  impossible,  or  but  imperfectly  accom- 
plished, the  growth  not  only  enlarges  in  accordance  with  its 
special  character  for  virulence,  but  spreads  by  local  dissemina- 
tion, regional  dis>semination,  and  general  dissemination  until 
such  time  as  the  life  of  the  human  host  is  terminated  by  its 
encroachments. 

Local  Dissemination. — By  local  dissemination  is  meant  the 
migration  of  malignant  cells  into  the  tissues  in  the  immediate 
neighborhood  of  the  original  seat  of  the  growth.  'There  is 
every  reason  to  believe  that  all  of  the  more  malignant  cells 
possess  a  distinct  power  of  locomotion,  equal  at  least  to  the 
extra-vascular  motility  of  the  leucocytes,  and  that  the  process 
of  erosion  of  neighboring  tissues,  whether  soft  parts,  cartilage 
or  bone,  is  due  to  the  actual  burrowing  power  of  young  cells, 


i8  i       The  Search  for  Cancer  Germs. 

which  freely  penetrate  surrounding  parts  and  there  reproduce 
their  kind  by  kariokinetic  segmentation,  the  tumor  itself  grow- 
ing partly  by  a  coalescence  of  the  colonies  begotten  by  each 
emigrant  germ-cell  in  its  rapid  proliferation,  and  partly  by 
similar  reproduction  of  the  cells  within  the  edge  of  the  prin- 
cipal mass.  The  rapidity  and  virulence  of  this  growth  vary 
greatly  with  the  several  genera  and  species,  and  are  at  times 
controlled  somewhat  by  the  physiologic  resistance  (phagocytic 
resistance)  of  the  tissues  of  the  host.  It  results  in  the  forma- 
tion of  an  outlying  zone  of  dissemination  surrounding  a  malig- 
nant tumor,  made  up  of  distinct  colonies  which  have  planted 
themselves  in  normal  tissues,  which  they  consume  and  from 
which  they  drain  nutriment  and  trophic  force,  and  the  leuco- 
cytes of  an  inflammatory  process  which  the  body  forces  always 
marshal  more  or  less  strongly  against  the  diseased  cells.  The 
rapidity  and  extent  of  this  local  dissemination  vary  with  the 
particular  species  of  growth,  great  differences  being  found 
among  both  sarcomas  and  carcinomas. 

Regional  Dissemination. — A  carcinoma  is  disseminated  be- 
yond the  immediate  neighborhood  of  the  mother  tumor  almost 
exclusively  by  means  of  the  lymphatics.  In  the  process  of 
erosion  at  the  primary  seat  of  the  growth  the  migrating  cells 
invade  the  lymphatic  spaces  and  vessels  and  are  washed  along 
by  the  current  until  mechanically  arrested,  which  may  occur 
at  the  valves  in  these  vessels  but  necessarily  so  at  the  lymphatic 
glands.  It  has  been  said  that  the  larger  size  of  the  cells  in 
sarcoma  is  the  reason  why  this  mode  of  dissemination  is  mainly 
confined  to  the  carcinomata.  Since  the  lymphatic  glands  are 
the  filtering  points,  as  it  were,  in  this  system,  it  is  within  their 
glandular  structure  that  the  infective  emboli  are  usually  first 
arrested.  Further  migration  is  here  stayed  until  sufficient 
erosion  of  the  gland  tissue  results  to  permit  an  entrance  of  the 
cells  into  the  distal  lymphatics  leading  to  other  glands  in  the 
chain,  and  it  is  generally  not  until  the  whole  chain  is  affected 
that  the  migratory  cells  at  last  gain  entrance  into  the  general 
vascular  circulation,  permitting  general  dissemination  to  many 
organs  of  the  body.  The  practical  effect  of  regional  dissemi- 
nation, therefore,  delays  general  dissemination  by  a  most 
important  interval,  though  it  proves  that  the  original  focus  of 
infection  no  longer  contains  within  itself  the  whole  number  of 
malignant  cells.     An  important  lesson  to  be  learned  from  this 


General  Dissemination.  19 

barrier  or  filter  action  of  the  lymphatic  glands,  and  the  fact 
that  only  the  glands  nearest  the  growth  are  first  affected,  is  the 
unwisdom  of  removing  or  destroying  the  glands  of  a  region  in 
which  a  primary  cancer  exists  unless  they  are  themselves  pal- 
pably affected — a  mistake  not  infrequently  made  in  the  at- 
tempted thoroughness  of  modern  knife  operations. 

The  regional  dissemination  of  a  sarcoma  is  usually  accom- 
plished by  a  directly  continuous,  or  but  slightly  discontinuous, 
growth  of  the  tumor  along  the  fascize,  blood  vessels,  or  nerve 
sheaths — it  is  a  local  dissemination  on  a  large  scale  with  a 
special  preference  in  certain  directions.  A  sarcoma  may,  how- 
ever, be  disseminated  through  a  region  by  the  lymphatics  in  the 
same  way  as  a  carcinoma. 

General  Dissemination. — A  malignant  growth  does  not  be- 
come constitutional  in  any  sense  until  general  dissemination 
has  occurred ;  for  so  long  as  the  migrating  cells  are  confined 
to  the  seat  first  attacked,  and  even  to  the  lymphatic  glands  of 
the  region,  the  affection  is  a  strictly  local  disease.  When  the 
erosive  process  has  permitted  young  cells  to  escape  into  the 
blood  current,  either  directly  or  by  means  of  the  venous 
terminal  of  the  lymphatics,  the  cells  become  a  portion  of  the 
circulating  fluid  and  tend  to  lodge  as  emboli  in  the  capillaries 
of  various  internal  organs,  particularly  the  liver,  the  lungs, 
and  the  red  marrow  of  the  bones,  and  there  proliferate  and 
produce  daughter  tumors  in  every  respect  like  the  original 
growth.  By  reason  of  the  number  of  the  daughter  tumors  thus 
added  to  the  primary  malignant  invasion,  or  usually  by  reason 
of  the  vital  character  of  the  internal  organs  thus  attacked,  the 
blood  becomes  quickly  deteriorated  and  the  characteristic 
cachexia  of  malignant  disease  appears. 

The  appearance  of  this  cancerous  cachexia  is  therefore  a 
sure  sign  of  internal  dissemination  of  a  malignant  growth,  and 
usually  presages  a  certain  failure  of  any  efforts  yet  devised  to 
check  the  course  of  the  affection.  A  moderate  amount  of 
cachectic  discoloration  of  the  skin  may  be  present  in  some 
cases  while  the  disease  is  still  local,  nevertheless,  and  the  dis- 
appearance of  this  incipient  cachexia  during  the  use  of  the 
author's  method  of  treatment  on  several  occasions,  pari  passu 
with  the  destruction  of  the  malignant  cells,  makes  it  apparent 
that  the  true  nature  of  the  cachexia,  in  part  at  least,  is  that  of 
an  auto-intoxication  from  the  excretions  of  the  cancer  cells. 


20  The  SearcJi  for  Cancer  Germs. 

General  dissemination  may  occur  early  or  late  in  the  history 
of  the  primary  growth,  in  accordance  with  the  virulent  char- 
acteristics of  the  particular  species,  though  the  proneness  to 
early  metastasis  does  not  always  correspond  to  the  local 
virulence,  since  the  most  hopeless  general  infection  may  be 
found  to  exist  in  a  case  in  which  the  primary  growth  has  been 
neglected  on  account  of  its  small  size  and  slight  symptoms. 
The  diagnosis  of  the  presence  of  early  general  dissemination, 
when  but  one  or  two  internal  metastases  have  occurred,  is  at 
times  most  difficult,  and  the  surgeon  is  often  compelled  by  the 
dictates  of  humanity  to  give  a  patient  the  benefit  of  the  doubt 
and  proceed  to  destroy  the  primary  growth,  only  to  find  later 
the  inexorable  evidences  of  the  existence  of  an  internal  graft 
implanted  some  time  before  the  destruction  of  the  mother 
tumor.  Such  cases  remain  as  sad  examples  of  the  importance 
of  the  early  treatment  of  malignant  disease. 

The  wisdom  of  destroying  the  primary  growth  while  in 
doubt  as  to  the  presence  of  internal  metastasis,  is,  however,  at 
times  based  on  other  grounds,  for  the  clinical  features  that 
render  the  diagnosis  difficult — the  absence  of  pain,  hemorrhage, 
fetor,  etc.,  traceable  to  the  internal  growth — render  the  destruc- 
tion of  the  primary  tumor  a  valuable  palliation  of  the  last  days 
of  the  patient. 


CHAPTER  III. 

THE   DIFFERENTIAL   DIAGNOSIS    OF    MALIGNANT    GROWTHS. 

The  differential  diagnosis  between  benign  tumors  and  the 
several  varieties  of  malignant  growths  assumes  added  im- 
portance in  view  of  the  necessity  for  early  treatment  of  the 
latter  in  accordance  with  the  present  views  of  their  local  origin. 
It  is  indeed  easy  for  the  layman  to  diagnose  an  external  cancer 
in  its  last  stages,  but  the  success  of  any  rational  means  of  cure 
is  at  present  dependent  on  the  recognition  of  the  disease  in  a 
much  earlier  stage  of  its  progress.  The  early  recognition  of 
malignant  local  infections  is  therefore  one  of  the  most  press- 
ing duties  of  general  practitioners,  for  it  is  usually  the  family 
physician  who  is  the  first  to  be  appealed  to  by  the  patient,  and 
the  practical  usefulness  of  early  diagnosis  is  greatly  increased 
by  the  facility  with  which  a  small  growth  may  be  eradi- 
cated by  the  methods  described  in  this  work,  without  neces- 
sarily destroying  or  removing  the  organ  in  which  it  is  situated. 

With  this  means  at  hand  the  physician  is  in  a  position  to 
adopt  the  altered  aphorism,  "When  in  doubt,  destroy  the 
growth,"  in  all  small  tumors  of  the  skin  and  mucous  membranes 
and  all  suspicious  nodules  in  glandular  organs,  for  in  these 
cases  the  destruction  produced  by  the  application  is  limited 
to  the  growth  itself  and  its  immediate  peripheries,  and  the  dis- 
turbance of  the  patient  is  no  greater  than  would  be  necessary 
if  the  growth  be  really  benign,  the  methods  being  adapted  to  the 
destruction  of  the  latter  as  well.  The  use  of  cataphoric 
methods  greatly  simplifies  the  decision  to  destroy  small  sus- 
picious growths,  therefore,  relieving  the  surgeon  from  the 
two-horned  dilemma  of  leaving  a  small  focus  of  malignancy  to 
develop  further,  meantime  possibly  leading  to  metastasis,  in 
order  that  the  removal  of  the  whole  organ  may  be  justified 
without  doubt,  on  the  one  hand,  or,  on  the  other,  of  sacrificing 
an  entire  organ  for  what  turns  out  to  be  only  a  benign  neo- 
plasm. 

Clinical  Evidences  of  Malignancy  and  of  the  Species 
OF  A  Malignant  Growth. — As  has  been   stated,   the  chief 


22  Differential  Diagnosis.' 

clinical  evidence  of  a  neoplasm  being  of  a  cancerous  nature  is 
its  tendency  to  indefinite  increase  by  the  erosive  destruction  of 
neighboring  organs ;  and  while  the  microscopic  evidences  of 
this  condition,  shown  by  the  cells  being  misplaced,  in  greater 
abundance  than  normal,  and  unprovided  with  a  membrana 
propria,  must  be  regarded  as  the  standard  for  the  formation 
of  an  absolute  diagnosis,  there  are  many  clinical  evidences  of 
great  value  in  reaching  a  presumptive  diagnosis,  and  many  cir- 
cumstances in  which  the  latter  alone  must  be  depended  on  in 
the  absence  of  a  skilled  microscopist  and  where  delay  would 
endanger  the  patient.  The  clinical  evidences  are  in  certain 
cases  even  superior  to  histologic  evidences.  In  two  cases  under 
the  author's  observation,  one  of  carcinoma  and  the  other  of 
sarcoma,  the  patients  ultimately  died  of  repeated  recurrences  in 
spite  of  the  failure  of  several  skilled  histologists  to  find  micro- 
scopic evidences  of  malignancy. 

Probably  the  most  important  point  in  the  diagnosis  of  early 
malignant  growths  is  that,  contrary  to  the  prevailing  impres- 
sion among  the  people,  these  growths  are  rarely  painful  in  the 
stage  in  which  they  are  most  curable.  This  fact  is  one  of  the 
most  fruitful  causes  for  that  fatal  delay  which  yet  paralyzes 
remedial  effort.  A  slight  stinging,  or  uncomfortable  sensa- 
tion, is  usually  the  only  complaint  made,  until,  the  quickly 
proliferating  cells  having  finally  reached  sensory  nerve  trunks 
or  filaments,  the  severe  and  continuous  pains  of  advanced  local 
disease  are  suffered. 

The  age  of  the  patient  is  an  important  factor  in  reaching 
a  presumptive  diagnosis.  A  suspicious  lump  is  not  likely  to 
be  a  cancer  if  the  patient  is  under  thirty  years,  though  excep- 
tions to  this  rule  are  occasionally  met  with,  particularly  in  cases 
of  quickly  growing  so-called  congenital  sarcoma  in  children. 
The  writer  has  met  with  a  large  sarcoma  of  the  orbit  in  an 
infant  of  six  weeks  and  in  two  children  of  five  and  six  years, 
and  a  very  large  sarcoma  of  the  ovary  in  a  girl  of  fourteen. 
Carcinoma  is  more  rarely  found  than  sarcoma  in  these  early 
years,  though  fulminating,  highly  parasitic,  quickly-growing 
acinous  carcinoma  of  the  breast  may  be  encountered  in  women 
as  young  as  twenty-seven  to  thirty,  particularly  as  a  sequel  to 
miscarriage  or  normal  pregnancy. 

Rapidity  of  growth  is  of  course  a  marked  feature  of  a 
malignant  tumor,  yet  this  fact  is  at  times  apparently  wanting 


Evidences  of  Malignancy.  23 

in  those  carcinomas  to  which  the  older  name  of  scirrhus  was 
given,  the  truth  being  that  in  these  cases  the  progress  of  the 
disease  in  its  primary  site  is  held  in  check  by  the  physiologic 
resistance  of  the  individual,  which  permits  the  phagocytic  cells 
to  develop  into  connective  tissue  fibers  which  intersect  and 
compress  the  cancer  cells,  giving  rise  to  the  hardness.  Metas- 
tasis is,  however,  an  ever-present  danger  of  these  slowly  grow- 
ing carcinomas,  as  of  the  more  cellular  or  encephaloid  variety. 
The  rapidity  of  growth  of  a  cancer  is  a  product,  therefore,  of 
two  opposing  factors :  the  degree  of  malignancy  of  the  par- 
ticular germ,  and  the  phagocytic,  deterring  quality  of  the  type 
of  cell  of  the  individual.  A  rapidly  growing  carcinoma  must 
be  carefully  differentiated  from  inflammatory  infection,  the 
latter  being  accompanied  by  much  more  pain,  heat,  and  tender- 
ness, and  finally  by  fluctuation.  It  must  also  be  differentiated 
from  gummas,  tuberculosis,  actinomycosis,  and  chronic  sup- 
puration. 

A  primary  malignant  growth  is  very  rarely  multiple,  as  so 
frequently  happens  in  benign  tumors. 

The  mobility  and  contour  of  a  small  tumor  of  the  breast  are 
important  evidences  for  or  against  malignancy.  In  advanced 
stages  the  diagnosis  of  breast  cancer  is  exceedingly  easy,  even 
before  the  appearance  of  pain,  for  in  addition  to  the  lack  of 
tenderness,  the  whole  breast  is  immovably  fixed  to  the  sub- 
glandular  tissues.  When  it  is,  on  the  contrary,  yet  but  a  small 
nodule  situated  within  a  lobule  of  the  glandular  tissue  it  is  still 
movable,  though  it  does  not  slip  so  readily  betw^een  the  fingers 
as  a  benign,  encapsulated  adenoma.  Even  in  this  stage  the 
edges  are  more  nodulated,  showing  the  peripheral  prolonga- 
tions. At  a  later  stage  the  overlying  skin  becomes  attached  to 
a  carcinoma,  forming  a  dimple,  which  later  alters  in  color  and 
texture  by  an  extension  of  the  malignant  process  to  the  derm 
itself.  From  chronic  lobular  mastitis  it  is  differentiated  by 
better  defined  edges,  and  by  the  absence  of  tenderness. 

The  retracted  nipple,  when  its  fellow  is  normal,  is  a  valu- 
able diagnostic  sign  in  the  more  advanced  cases  of  contracting 
scirrhus  acinous  carcinoma.  At  times  the  nipple  is  pulled 
aside  in  the  direction  of  the  most  affected  lobule  of  the  breast 
as  well  as  retracted. 

The  principal  points  of  clinical  difference  between  carcinoma 
and  sarcoma  are :  that  carcinoma  invariablv  arises  in  situations 


24 


Differential  Diagnosis. 


where  epithelial  tissues  are  situated,  and  causes  regional  dis- 
semination by  way  of  the  lymphatics,  while  sarcoma  arises  in- 
variably beneath  the  unchanged  skin  or  mucous  membrane 
where  connective  tissues  are  normally  prevalent,  and  causes 
regional  dissemination  mainly  by  way  of  the  blood  vessels  and 
cellular  planes  of  the  tissues. 

The  following  table  presents  the  characteristic  differences 
between  sarcoma  and  carcinoma  in  a  synoptical  form: 


SARCOMA. 

CARCINOMA. 

Origin. 

Connective   tissue. 

Epithelium. 

Composition. 

Immature  con.  tis. 

Epithelial  cell,  fibrous 
stroma. 

Age. 

Before  middle  life. 

After  35. 

Sex. 

More  common  in  men. 

More  common  in 
women. 

Heredity. 

No  influence. 

May  influence. 

Seats. 

Connective  tissues. 

Epithelial  sur  faces- 
and  glands. 

Metastasis. 

By  blood  vessels. 

By  lymphatics. 

Growth. 

More  rapid,  often  in- 
termittent. 

Usually  slower. 

Outline. 

Rounder,     more     cir- 
cumscribed. 

Nodular,  irregular. 

Local  Infiltration. 

Less  marked. 

Widespread". 

Cut  section. 

Convex. 

Concave. 

Adipose  tissue. 

Absent. 

Usually  present. 

Juice. 

Often  absent. 

Present. 

Color. 

Reddish    grey,     more 

Grevish  white,  granu- 

translucent. 

lar. 

Melanosis. 

Not  uncommon. 

Rare. 

Ulceration. 

Uncommon,      superfi- 
cial. 

Common,   deep. 

Adjacent  skin. 

Often  uninvolved. 

Infiltrated. 

Intercellular  substance. 

Always  present. 

Absent. 

Alveolar  structure. 

Uncommon. 

Constant. 

Cells  and  stroma. 

Intimate  association. 

No  close  connection. 

Blood  vessels. 

Between  cells. 

In   stroma   only. 

Blood  vessel  walls. 

Often  imperfect. 

Well  formed. 

Lymphatics. 

Absent. 

Present. 

Clinical  Examination  with  Reference  to  Stage  of  Growth  and 
Advisability  of  Surgical  Intervention. — In  the  practical  exami- 
nation of  a  growth  palpation  is  of  the  greatest  importance,  as 
by  the  educated  touch  we  may  determine  its  limits ;  whether 
cystic  or  solid  (transillumination  being  at  times  a  valuable 
means  of  verifying  fluctuation)  ;  whether  pulsation  is  present 
in  the  growth  or  is  communicated  to  it  by  underlying  arteries 
(by  lifting  it  away  from  the  latter)  ;  the  nearness  of  important 
vessels ;  whether  the  malignant  process  is  still  confined  to  an- 
organ  or  is  diffused  beyond  it ;  and,  most  important  of  all^ 
whether  the  glands  draining  the  part  are  enlarged  or  not. 


Clinical  Examination.  25 

The  local  examination  should  also  be  preceded  or  followed 
by  a  general  examination  of  the  patient,  directed  especially  to 
determine  the  presence  or  absence  of  secondary  growths  in  the 
chest  or  abdomen;  the  condition  of  the  arteries  and  of  the 
kidney  excretion;  and  a  blood  count  should  be  made. 

The  blood  examination  is  of  but  little  value  in  the  earlier 
stages  of  a  growth,  but  in  the  presence  of  metastasis  the  num- 
ber of  red  blood  cells  is  decreased,  falling  sometimes  to  1,500,- 
000  to  the  cubic  millimeter,  though  usually  not  getting  lower 
than  3,500,000.  Should  the  hemoglobin  index  fall  to  50  per 
cent,  the  patient  is  apt  to  be  too  weak  for  any  form  of  opera- 
tion. 

The  leukocytes  are  usually  unaffected  in  the  absence  of 
metastasis,  though  Avhen  this  is  present  they  may  be  increased, 
as  in  any  wasting  disease.  In  carcinoma  in  certain  situations, 
such  as  the  uterus,  the  kidney,  and  particularly  the  pancreas 
and  thyroid,  there  may  be  a  marked  increase  in  the  leukocytes. 

Microscopic  Diagnosis. — ^Although  much  can  be  learned 
from  the  clinical  history  and  the  examination  of  the  patient, 
yet  the  very  early  recognition  of  the  existence  of  malignant 
disease  can  be  made  only  by  means  of  the  microscope.  When 
the  condition  has  advanced  to  the  point  where  the  diagnosis 
can  be  made  by  the  clinician  the  hope  of  helping  the  patient  is 
reduced  to  a  minimum. 

In  making  a  diagnosis  of  malignancy  by  the  microscope 
certain  characteristics  of  the  various  growths  must  be  taken 
into   consideration. 

As  already  mentioned,  malignant  tumors  may  be  classified 
under  two  headings  according  to  the  layer  of  the  blastoderm 
from  which  they  are  developed.  There  are  the  epithelial 
tumors,  the  carcinomata,  and  the  mesoblastic  or  sarcomatous 
growths. 

In  the  carcinomas  there  is  a  distinctly  atypical  arrangement 
of  the  epithelium  and  the  connective  tissue.  The  epithelial  ele- 
ments are  arranged  eitjier  in  solid  nests  or  masses  surrounded 
by  adult  connective  tissue,  or  else  there  is  an  abnormal  arrange- 
ment of  imperfect  acini. 

The  carcinomas  differ  greatly  in  appearance  according  to 
the  part  of  the  body  that  they  occupy.  When  on  the  surface 
of  the  body  they  are  generally  flat  or  slightly  nodular.  It  is 
such  tumors  as  these  that  frequently  undergo  inflammatory 


26  Differential  Diagnosis. 

change  and  ulceration  on  account  of  their  being  so  exposed  to 
injury. 

The  growths  arising  from  the  mucous  membranes  are  usually 
rather  soft  and  present  frequently  a  cauliflower  appearance. 
They  may  also  undergo  inflammation,  or  they  may  appear 
primarily  in  the  form  of  an  ulcer. 

When  a  carcinoma  develops  within  a  glandular  organ  of  the 
body  it  generally  appears  as  an  irregular  infiltrating  mass,  that 
will  be  hard  or  soft  according  to  the  amount  of  cellular  tissue 
present. 

The  type  of  the  cell  that  forms  the  carcinoma  depends  upon 
the  variety  from  which  it  grew.  In  the  squamous  epithelio- 
mata  the  cells  resemble  those  of  the  squamous  variety,  such  as 
are  found  covering  the  skin.  The  cells  are  large  and  flat,  with 
a  large  vesicular  and  centrally  located  nucleus. 

In  those  arising  from  the  glandular  mucous  membranes  and 
from  the  glandular  organs  the  cells  are  usually  columnar  or 
cuboidal. 

It  was  formerly  thought  by  some  investigators  that  the 
diagnosis  of  malignancy  could  be  made  from  the  cells  alone 
on  account  of  their  atypical  appearance.  Such,  however,  is 
not  the  case,  the  abnormalities  of  the  shape  and  size  of  the 
cells  being  accidental  conditions,  resulting  probably  from  the 
compression  brought  about  by  the  growth  of  the  tumor. 

The  diagnosis  of  malignancy  depends  rather  on  the  general 
relation  of  the  tissues  than  upon  individual  characteristics  of 
the  cells. 

Normally,  in  an  acinus  of  a  gland  the  epithelial  cells  gen- 
erally occur  in  a  single  layer  resting  upon  a  very  thin  but  well- 
formed  basement  membrane  of  adult  connective  tissue  that 
separates  them  from  the  surrounding  tissues.  In  a  so-called 
adeno-carcinoma  the  cells  are  found  to  have  done  either  or 
both  of  two  things.  They  may  have  undergone  such  a  pro- 
liferation as  to  have  more  or  less  completely  filled  up  the 
acinus.  In  such  a  condition  instead  of  a  single  layer  of  uniform 
cells  there  will  be  many  layers  of  atypical  ones.  These  epi- 
thelial tumors  are  frequently  classified  as  Simple,  Scirrhous, 
and  Medullary,  according  as  to  whether  the  amounts  of  con- 
nective tissue  and  epithelium  are  about  equal,  or  the  former 
or  latter  elements  predominate. 

On  the  one  hand,  the  basement  membrane  may  have  sue- 


Microscopic  Examination.  27 

cumbed  to  the  malignant  effects  and  the  cells  will  have  invaded 
the  surrounding  tissues.  According  to  the  plane  of  the  section 
examined,  there  may  be  found  these  masses  of  atypical  cells 
isolated  from  any  acinus,  or  the  point  of  rupture  through  the 
basement  membrane  may  be  disclosed. 

In  the  so-called  epitheliomata  the  papillae  of  the  skin  will  be 
found  to  extend  deeply  into  the  underlying  tissues.  The  re- 
straining power  governing  the  growth  of  the  cells  is  apparently 
destroyed  and  the  epithelium  infiltrates  the  surrounding  struc- 
tures. In  many  places  the  cells  will  be  found  concentrically 
arranged,  forming  the  epithelial  pearls.  In  these  areas  the 
cells  will  frequently  have  undergone  a  transformation  into 
keratin. 

It  should  be  remembered,  however,  that  these  pearls  do  not 
indicate  malignancy ;  they  show  nothing  more  than  that  the  par- 
ticular growth  arose  from  squamous  epithelium.  Carcinomata, 
having  grown  to  some  size,  very  commonly  show  various  forms 
of  degeneration,  the  most  frequent  being  a  fatty  change.  Like 
all  other  epithelial  structures,  a  parenchymatous  degeneration 
of  the  cells  is  often  found.  The  protoplasm  will  be  swollen 
and  cloudy,  and  the  nuclei  may  be  very  indistinct  or  even  com- 
pletely concealed. 

The  connective  tissue  present  may  undergo  a  myxomatous 
change  and  give  rise  to  the  so-called  colloid  cancer,  an  incor- 
rect definition,  as  the  change  is  not  within  the  epithelium  but 
within  the  fibrous  stroma. 

Occasionally  the  cancer  may  become  cystic,  either  by  a  block- 
ing up  or  absence  of  an  excretory  duct,  or  by  degeneration 
of  the  growth  itself. 

There  may  be  a  deposit  of  lime  salts  within  the  degenerated 
areas. 

There  may  also  be  secondary  inflammatory  changes,  brought 
about  by  the  infection  of  the  tumor  by  some  organism,  par- 
ticularly the  streptococcus  or  staphylococcus. 

The  sarcomata,  or  malignant  mesoblastic  tumors,  are  com- 
posed of  tissue  that  in  its  form  resembles  to  a  certain  extent 
embryonal  connective  tissue.  It,  however,  differs  from  it  in 
that  in  the  sarcoma  the  cells  never  attain  an  adult  condition,  and 
they  do  not  all  originate  as  round  cells,  as  do  normal  varieties 
of  connective  tissue.  The  growth  may  be  composed  from  its 
earliest  stages  of  spindle  cells  and  not  show  any  attempt  at 


28  Differential  Diagnosis. 

true  connective  tissue  formation,  no  matter  how  long  the 
tumor  might  exist. 

A  sarcoma  is  generally  more  circumscribed  and  nodular 
than  a  carcinoma,  and  is  frequently  decidedly  pinkish  in  color 
on  account  of  the  amount  of  blood  present.  It  may  vary  in 
hardness,  depending  upon  the  amount  of  intercellular  sub- 
stance present.  It  may  become  soft  through  degenerative 
changes. 

These  tumors  may  arise  wherever  there  is  a  pre-existing 
connective  tissue.  Consequently  they  may  be  found  in  any  part 
of  the  body,  externally,  or  within  the  internal  organs. 

The  microscopic  examination  shows  why  metastasis  in  the 
sarcoma  takes  place  by  means  of  the  blood  vessels.  The  tumor 
is  made  up  of  undeveloped  connective  tissue,  and  the  blood 
vessels,  instead  of  having  well-formed  walls,  have  usually  a 
single  layer  of  flat  endothelial  cells.  Even  this  slight  protection 
is  often  absent,  the  endothelium  being  present  in  a  very  imper- 
fect condition.  Consequently  the  blood  channel  is  often  sur- 
rounded by  nothing  more  than  a  mass  of  tumor  cells.  As  a 
result  of  this,  very  slight  degenerative  changes  in  the  tumor 
allow  the  cells  to  be  set  free  within  the  circulation.  They  are 
then  carried  to  the  small  capillaries,  in  which  they  lodge  and 
grow. 

In  carcinomata,  on  the  other  hand,  the  connective  tissue  that 
is  present  in  varying  amounts  between  the  collections  of  atypical 
epithelial  cells  is  fully  developed,  and  it  is  there  that  the  blood 
vessels  are  found.  They  are  thus  separated  from  intimate 
contact  with  the  tumor  cells,  and  consequently  metastasis  of 
carcinoma  by  the  blood  is  comparatively  rare. 

In  sarcoma  there  is  little  or  no  tendency  towards  fibrous 
tissue  formation.  There  is,  however,  a  great  multiplication  and 
increase  in  the  number  of  cellular  elements. 

According  to  the  variety  of  cell,  the  sarcoma  may  belong 
to  one  of  the  following  types :  Round  cell,  spindle  cell,  or 
giant  cell.  It  may  be  known  as  an  angio-sarcoma  if  it  has  had 
its  origin  from  the  adventitia  of  the  blood  vessels,  or  it  may  be 
a  melanotic  sarcoma  if  pigment  in  the  form  of  melanin  is  pres- 
ent. This  pigment  differs  from  the  coloring  matter  of  the 
blood  in  that  it  does  not  contain  iron.  The  round-cell  sarcoma 
is  composed  of  cells  that  may  be  either  large  or  small.  In  them 
there  is  very  little  intercellular  substance,  the  cells  greatly  pre- 


Microscopic  Examination.  29 

dominating.  They  are  grayish  or  pinkish  in  color,  and  fre- 
quently exude  a  milky  fluid.  They  are  always  malignant,  and 
the  smaller  the  cell  the  more  marked  is  the  predisposition  to 
general  involvement. 

The  spindle-cell  form  may  also  be  divided  into  large  or 
sm.all  according  to  the  size  of  the  cell  present.  They  are  usu- 
allv  comparatively  firm,  and  sometimes  the  intercellular  sub- 
stance is  so  well  marked  that  the  tumor  may  be  called  a  fibro- 
sarcoma. At  times  it  is  very  difficult  to  decide  whether  or  not 
the  tumor  is  sarcomatous  or  fibrous.  As  a  rule,  they  are  not 
very  malignant;  quite  frequently  they  do  not  give  metastasis. 

The  giant-cell  sarcoma  usually  arises  from  the  periosteal 
covering  and  gets  its  name  from  the  fact  that  in  it  we  find 
many  cells  containing  two  or  more  nuclei.  Incidentally,  it 
should  be  remembered  that  the  term  giant  cell  wherever  met 
with  does  not  refer  to  the  size  of  the  cell ;  it  indicates  only  that 
there  are  more  than  one  nucleus.  These  tumors  are  slow  in 
growth,  usually  quite  hard,  and  are  practically  benign,  very 
seldom  giving  rise  to  metastasis. 

The  angio-sarcoma  is  seen  to  consist  of  irregular  masses  of 
cells  surrounding  blood  vessels.  They  frequently  undergo  a 
myxomatous  degeneration,  and  hemorrhage  into  the  surround- 
ing tissues  may  result.  As  a  general  rule,  they  do  not  tend  to 
give  metastasis. 

The  melanotic  sarcoma  is  one  that  may  be  made  up  of  cells 
of  any  variety  and  of  any  arrangement,  but  it  contains  melanin. 
This  coloring  matter  may  occur  either  within  or  between  the 
cells.  This  form  most  frequently  arises  in  pigmented  moles  of 
the  skin  or  within  the  eye.  It  is  exceedingly  malignant,  grows 
very  rapidly,  and  gives  extensive  metastasis,  particularly  in  the 
liver,  the  secondary  growths  frequently  containing  more  pig- 
ment than  the  primary  tumor. 


CHAPTER  IV. 

THE    DESTRUCTION     OF    MALIGNANT    GROWTHS    BY    THE    LOCAL 
CATAPHORIC    DIFFUSION    OF    METALLIC    IONS. 

Whatever  truth  may  be  uncovered  by  the  further  study  of 
maHgnant  disease,  there  can  be  only  corroboration  and  ex- 
planation of  at  least  one  or  two  facts  already  in  our  possession, 
the  correctness  of  which  has  been  amply  proven.  Of  these 
the  most  important  relates  to  the  purely  local  character  of  the 
primary  growth  at  its  first  appearance,  and  the  possibility  of  its 
eradication  in  this  stage  by  the  use  of  effective  means.  We 
may  be  as  yet  unaware  of  the  reason  why  the  cells  of  a  can- 
cerous tumor  possess  the  power  of  migrating  into  and  eroding 
surrounding  tissues — the  central  fact  of  malignancy — but  we 
do  know  that  the  potential  energy  of  a  cancer  resides  within  or 
between  these  cells,  and  that  this  potential  energy  may  be  de- 
stroyed by  the  complete  removal  or  destruction  of  all  abnormal 
activity  in  the  affected  region. 
I  It  may  be  unequivocally  stated,  therefore,  that,  in  spite  of 
our  ignorance  of  the  true  nature  of  the  cancer  cell,  an  incipient 
cancerous  grozvth  in  an  accessible  situation,  zvhich  has  not 
given  rise  to  metastasis,  may  he  totally  destroyed  by  appro- 
priate means,  thus  curing  the  patient.  Cancer  is,  therefore, 
curable,  under  the  conditions  mentioned,  and  the  full  realization 
of  this  fact  is  of  the  utmost  importance  to  sufferers.  Of  equal 
importance  is  the  knowledge  that  internal  metastases  occur 
very  early  in  many  forms  of  cancer,  and  that  when  this  has 
been  permitted  to  happen  through  delay  there  is  at  present  no 
knozvn  means  of  cure. 

Referring,  therefore,  wholly  to  growths  still  local,  or  with 
but  slight  and  yet  accessible  regional  dissemination,  the  ques- 
tion of  greatest  importance  relates  to  the  best  method  of 
destruction  or  removal,  for  at  present  no  other  means  of  cure 
exists.  It  is  to  this  class  of  so-called  operable  cases  that  this 
work  is  intended  mainly  to  refer,  though  many  of  the  cases 
recorded  in  these  pages  show  the  difficulty  of  selecting  them 

30 


Limitations  of  Other  Methods.  31 

while  yet  in  this  stage,  and  illustrate  the  value  of  the  method 
as  at  least  a  palliative  in  the  inoperable  class. 

The  recent  history  of  radiotherapy  indicates  that  the  hopes 
entertained  at  first  for  x-radiation  as  an  effective  method  in 
operable  growths  have  resulted  in  disappointment,  except  for 
epitheliomas  of  the  skin.  The  feeling  is  apparently  general 
that  the  rays  should  be  preceded,  at  least,  by  more  positive 
operative  methods  when  possible.  A  fuller  recognition  of  the 
dangers  of  metastasis  occurring  during  the  prolonged  treat- 
ment by  this  method  should  accentuate  this  reluctance  to  trust 
to  it  alone  in  the  classes  most  liable  to  this  sequel.  Until 
massive  ionic  sterilization  was  proposed  for  certain  cases 
we  were,  therefore,  thrown  back  on  the  knife,  thermocautery, 
and  caustics  as  the  surgical  remedies  promising  operative 
cure. 

Removal  of  all  affected  cells  and  intercellular  substances  by 
the  knife,  thermocautery,  and  caustics  has  unquestionably  been 
accomplished  in  some  instances,  particularly  since  the  adoption 
of  the  modern  extensive  knife  operations  in  which  all  sur- 
rounding tissues  are  removed  at  the  same  time  with  the  growth, 
and  there  can  be  no  question  but  that  a  larger  number  of  suc- 
cessful results  would  follow  an  earlier  resort  to  the  latter 
form  of  operation  than  the  usual  dread  of  the  knife  permits. 
But  the  continuing  disfavor  of  the  knife  in  the  treatment  of 
cancer  is  doubtless  in  part  due  to  unwise  attempts  to  employ  it 
where  complete  removal  is  impossible,  or  where  the  act  of 
removing  the  growth  has  resulted  in  such  handling  of  the  / 
tumor,  still  laden  with  living  cancer  cells,  as  to  result  in  an 
operative  reimplantation  of  the  cells  in  the  cut  edges  of  the 
wound.  It  is  at  least  certain  that  what  progress  has  been  made 
of  late  in  the  knife  treatment  of  cancer  is  along  lines  that  make 
this  reimplantation  unlikely.  Unless  the  growth  has  been  re- 
moved to  its  remotest  prolongations,  together  with  all  infected 
glands,  without  zvounding  the  growth  itself  or  permitting  the 
tumor  juices  to  come  into  contact  with  the  cut  edges  of  the 
healthy  tissue,  the  results  will  be  no  better  than  those  attained  ' 
in  the  past — results  that  were  indicated  in  the  statement  of  the 
late  D.  Hayes  Agnew  that  he  had  removed  a  cart-load  of  can- 
cerous tumors  in  his  time,  but  that  all  the  patients  from 
whom  they  had  been  removed  had  ultimately  died  of  the 
disease. 


32  Destruction  by  Metallic  Ions. 

How  difficult  this  complete  removal  without  reimplantation 
is  of  accomplishment  in  some  cases  only  the  practical  surgeon 
knows.  In  many  situations,  particularly  within  cavities,  it  is 
essentially  impossible;  and  much  attention  has,  therefore,  been 
given  to  the  thermocautery,  either  alone  or  following  an  at- 
tempt at  removal  with  the  knife.  Used  alone,  the  thermo- 
cautery or  caustic  pastes  cannot  be  relied  upon  to  secure  suffi- 
cient pehetration;  when  used  after  the  attempted  extirpation 
with  the  knife  or  curette  it  is  extremely  likely  that  the  cancer 
cells  have  already  been  aspirated  into  the  cut  veins  or  Ivm- 
phatics  to  set  up  regional  or  general  metastases. 

With  the  sole  exception  of  the  wide-sweeping  knife  opera- 
tion, the  surgical  methods  mentioned  are,  therefore,  ineffective 
or  prone  to  cause  operative  reinfection,  and  thus  not  only  fail 
of  their  object,  but  lead  directly  to  an  intensification  of  the 
disease. 

That  wide-sweeping  knife  operations  are  at  times  themselves 
ineffective  can  only  be  due  to  the  fatal  delay  that  permits  metas- 
tases to  be  implanted  before  operation  in  cases  that  should  have 
been  operated  upon  many  weeks,  months,  and  even  years  be- 
fore consent  was  given.  Against  this  form  of  mental  delin- 
quency on  the  part  of  sufferers  no  operative  remedy  is  of  avail. 

The  Author's  Method.— What,  then,  are  the  conditions  to 
be  met  in^  those  cases  where  the  wide-sweeping  knife  opera- 
tion is  inadmissible? 

For  effective  results  in  such  cases  we  must  have  a  method 
that  acts  as  quickly  and  thoroughly  as  the  knife  in  a  favorable 
case  for  that  method,  and  yet  is  capable  of  application  through 
the  growth  itself,  from  within  outwards,  enabling  us  to  reach 
the  actual  periphery  of  the  latter  by  a  combined  destructive 
and  occlusive  agency,  devitalizing  all  cells  in  situ  and  sterilizing 
the  outermost  edge  while  at  the  same  instant  sealing  the  ab- 
sorbents, thus  effectually  preventing  operative  reinfection.  H 
the  growth  be  within  a  cavity,  this  force  must  be  conveyed 
along  a  conductor  that  is  of  small  caliber  and  often  tortuous, 
and  the  conductor  must  be  capable  of  thorough  insulation  of 
the  force  when  traversing  non-affected  parts,  thus  permitting 
the  destructive  effect  to  be  directed  and  controlled  at  will.  If 
this  agency  be  also  absolutely  bloodless,  and  leaves  as  a  product 
of  its  action  sufficient  antiseptic  chemicals  interstitially  diffused 
throughout  the  growth,  and  in  chemical  union  with  its  devital- 


The  Author's  Method.  33 

ized  cells,  to  maintain  an  absolutely  aseptic  condition  until  the 
dQbris_separates — it  woulGrseem^to^Bea  most  valuabTe  method" 
where  a  perfect  knife  removal  is  impossible. 

Not  only  are  each  and  every  one  of  these  indications  met  by 
the  massive  diffusion  of  the  ions^ of  mercury  and  zinc  by  power- 
ful electric  currents,  as  devised  and  developed  by  the  author 
during  the  past  sixteen  years,  but  still  another  result  of  value 
follows  the  production  of  such  an  area  of  sterilization  coter- 
minous with  a  malignant  growth :  for  beyond  this  area  of  total 
necrosis  the  diminishing  density  of  the  diffused  ions  will  pro- 
duce a  zone  of  reaction  of  slightly  further  dispersion,  suffi- 
ciently infiltrated  with  the  ionized  chemicals  to  destroy  outlying 
latent  cancer  cells  while  only  arousing  the  physiologic  resist- 
ance of  the  normal  tissues. 

The  basal  facts  developed  by  the  author  in  the  study  of  this 
process  are  that,  in  the  utilization  of  the  electrolytic  and  phoretic 
powers  of  a  strong  electric  current  for  dissolving  and  ionizing 
zinc  points  or  needles  coated  with  mercury  and  thrust  into  the 
growth,  a  quantity  of  ionized  mercury  and  zinc  may  be  inter- 
stitially  diffused  throughout  a  tumor  in  a  few  minutes,  with  the 
patient  usually  under  an  anesthetic,  that  will  be  sufficient  to 
kill  all  malignant  cells  and  their  accompanying  germs,  if  the 
latter  be  present ;  and  that  by  prolonging  the  process  sufficiently 
these  microbicidal  substances  will  be  driven  further  than  the 
apparent  boundaries  of  the  growth  in  sufficient  strength  to  kill 
outlying  colonies  and  lines  of  dissemination  in  the  immediate 
neighborhood,  without  serious  detriment  to  the  healthy  tissues 
in  this  situation.  In  other  words,  while  all  tissues  will  be 
necrosed  en  masse  near  the  electrode,  producing  an  area  of 
sterilisation,  the  diffusion  may  be  so  regulated  and  directed 
that  a  sufficient  quantity  will  pass  beyond  the  line  of  demarca- 
tion and  kill  outlying  cancer  cells  by  arousing  the  tissue  de- 
fenses, forming  thus  a  narrow  zone  of  reaction  beyond  the 
area  of  sterilization. 

The  diagram,  Fig.  i,  illustrates  what  happens  in  a  surface 
growth  under  a  strong  current  with  a  free  supply  of  zinc- 
mercury  points.  The  evident  portion  of  the  tumor  will  become 
shrunken,  and  softer,  and  will  change  in  color  to  a  grayish- 
white  in  from  five  minutes  to  one  hour,  under  a  current  appro- 
priate to  the  size  of  the  growth,  all  living  structures  being 
bloodlessly  devitalized.     The  limits  of  total  necrosis  are  sharply 


34 


Destruction  by  Metallic  Ions. 


defined,  and  become  later  the  site  of  the  line  of  demarcation  as 
nature  throws  off  the  dead  material. 

In  spite  of  the  employment  of  a  current  that  will  develop 
large  quantities  of  ionized  mercury  and  zinc  and  impregnate 
considerable  areas  with  it,  the  general  system  of  the  patient  is 
protected  from  the  absorption  of  all  but  a  minute  quantity  by 
reason  of  the  sealing  of  the  absorbents  by  the  necrosing  action 


Dispersing  Pad 
pliant  metallic  plate 


Fig.   I. — Diagram   of  monopolar  ionic  operation  in  a  case   of   cancer 

of   the   breast. 

of  the  metallic  ions  where  densely  diffused.  None  of  that  de- 
posited within  the  area  of  sterilization  can,  therefore,  be  ab- 
sorbed, theoretically,  and  clinical  experience  shows  so  little,  if 
any,  absorption  after  the  most  extensive  operations  that  it  is 
probable  that  the  portion  deposited  beyond  the  line  of  demarca- 
tion comes  away  in  the  discharges  during  the  process  of  healing, 
in  large  part.  In  fact,  it  has  seemed  to  the  author  that  the 
small  portion  of  these  antiseptic  chemicals  thus  probably  ab- 
sorbed within  the  system  and  eliminated  by  the  emunctories 
may  account  for  the  quick  improvement  in  the  general  health 
after  operation  in  cases  showing  a  preoperative  anemia  without 
metastasis,  though  this  improvement  may  really  be  due  to  the 
immediate  destruction  of  the  toxin-generating  malignant  cells. 

The  subsequent  history  of  a  growth  subjected  to  the  major 
application  with  strong  currents  is  most  interesting.  On  the 
completion  of  the  application  it  will  be  noted  that  the  whole 
mass  of  the  tumor  is  of  a  grayish-white  color,  and  that  if  odor 
has  been  present  it  no  longer  exists.  All  tendency  to  bleeding 
has  also  been  arrested,  of  course. 

On  emerging  from  the  anesthetic  the  patient  experiences  no 


The  Author's  Method.  35 

pain,  but  considerable  soreness.  By  the  next  day  a  puffy, 
reddened  zone  will  be  found  surrounding  the  area  of  steriliza- 
tion and  occupying  the  situation  of  the  zone  of  reaction.  This 
is  somewhat  tender  on  pressure.  By  the  third  day  a  tendency 
towards  the  formation  of  a  blister  is  seen  along  the  site  where 
the  line  of  demarcation  will  form,  and  when  this  line  forms 
some  days  later  a  lead-colored,  odorless  serous  discharge  will 
appear  and  continue  until  the  separation  of  the  dead  mass, 
the  latter  event  occurring  from  seven  days  to  three  weeks  from 
the  date  of  operation.  The  cavity  thus  made  heals  quickly  by 
granulation  and  cicatrization,  and  with  a  soft  and  compara- 
tively small  scar,  there  being  none  of  the  tedious  delays  and  un- 
certainty incident  to  x-ray  burns. 

How  THE  Method  was  Discovered. — During  the  summer . 
of  1893  the  author  attempted  the  treatment  of  an  adeno- 
carcinoma of  the  groin  in  a  gentleman,  at  his  request,  destroy- 
ing at  first  the  mass  of  the  tumor  by  ordinary  bipolar  electrol- 
ysis, and  then  changing  the  method  to  positive  cauterization 
with  a  blunt  electrode  of  carbon.  But  slow  progress  was  being 
made  under  the  use  of  currents  of  about  100  milliampere^ 
applied  daily,  this  strength  being  made  endurable  by  the  simul- 
taneous cataphoric  dispersion  of  cocaine  solution  from  the 
cavity,  when  it  was  noticed  that  the  carbon  electrode  showed 
signs  of  roughening  under  its  repeated  employment  as  a  posi- 
tive pole.  It  now  occurred  to  the  author  that  a  zinc  electrode 
would  be  better,  since  the  materials  formed  by  its  erosion  would 
assist  in  the  destructive  process.  This  had  been  either  done  or 
suggested  in  other  diseases  than  cancer  by  a  number  of  writers 
on  cataphoresis,  particularly  Gautier  of  Paris  and  Morton  and 
Cleaves  of  this  country.  A  suitable  instrument  was  accord- 
ingly fashioned  from  a  Leclanche  zinc  rod  and  apphed,  with- 
out any  appreciable  change  in  the  effect  with  the  current 
strength  used.  As,  however,  the  active  surface  of  the  zinc 
was  found  to  be  blackened  and  roughened  by  the  formation 
of  oxides  from  the  contained  ferric  impurities  of  commercial 
zinc,  it  now  occurred  to  the  author  that  a  free  amalgamation 
of  the  zinc  with  mercury  would  be  of  the  same  value  here  as 
when  the  zinc  is  employed  within  a  battery :  i.  e.,  keep  it  clean 
by  reason  of  being  coated  with  a  layer  of  pure  zinc  in  mercuric 
solution.  The  thought  also  arose,  but  distinctly  secondary, 
that  possibly  the  mercury  could  also  be  chemically  changed  and 


36  Destruction  by  Metallic  Ions. 

diffused  with  the  zinc,  though  it  was  known  that  this  did  not 
occur  within  the  battery.  This  was  accordingly  done,  and  with 
a  hundred  milhamperes  turned  on  there  soon  appeared  a 
whitish  pellicle  beneath  and  around  the  instrument,  distinctly 
different  from  that  following  the  previous  use  of  the  zinc.  The 
next  day  the  importance  of  the  discovery  thus  made  was  evi- 
dent when  it  was  noticed  that  the  unpleasant  odor,  which  had 
begun  to  issue  from  the  eroded  cavity,  had  ceased,  and  that 
the  area  of  induration  on  the  side  of  the  cavity  against 
which  the  electrode  had  been  applied  was  lessened.  The 
method  was  now  continued  in  this  mild  form  with  most  notable 
effects,  as  detailed  elsewhere,*  and  though  the  ultimate  result 
was  not  a  cure  in  this  case,  enough  was  seen  of  the  effects  of 
the  method  to  encourage  further  trial.  It  was  not  until  the 
spring  of  1896,  and  after  the  successful  application  of  this 
mild  method  to  one  case  of  sarcoma  of  the  palate  in  1894,  that 
the  stronger  method  under  an  anesthetic  was  essayed,  and 
again  the  results  were  most  important,  though  first  seen  in  a 
case  that  was  then  failing  from  internal  metastasis. 

The  effects  observed  in  this  latter  case  demonstrated  incon- 
testably  and  for  the  first  time  that  a  zone  of  infiltration  would 
form  beyond  the  area  devitalized  by  the  more  densely  diffused 
chemicals,  and  that  within  this  zone  a  reaction  would  occur, 
accompanied  by  a  disappearance  of  malignant  characteristics 
in  this  situation.  A  current  of  one  thousand  milliamperes  was 
applied  in  a  bipolar  manner,  several  zinc-mercury  electrodes 
connected  together  and  to  the  positive  pole  being  thrust  into 
the  periphery  of  the  tumor,  while  the  circuit  was  completed 
by  a  cotton-covered  disk  saturated  with  Fowler's  solution  con- 
nected with  the  negative  pole  and  placed  against  its  center. 
This  resulted  in  the  diffusion  of  zinc-mercury  ions  from 
each  anode  in  the  periphery,  and  of  arsenic  ions  from  the  nega- 
tive disk  in  the  center.  Areas  of  devitalization  appeared  in  a 
few  minutes  in  each  situation,  namely :  a  large  one  beneath  the 
disk  in  the  center,  and  smaller  ones  around  each  zinc-mercury 
electrode  in  the  periphery,  accompanied  by  a  general  shrinkage 
of  the  growth.  After  fifteen  minutes  the  current  was  turned 
off  and  the  patient  put  to  bed.  On  removing  the  dressing 
the  next  morning  I  was  surprised  to  find  that  the  indurated 
tissues  that  lay  between  the  small  areas  of  necrosis  had 
*  Transactions  American  Electro-Therapeutic  Association,  1900. 


General  Prognosis.  37 

changed  color  from  a  purplish  to  a  pink  tint,  and  were  puffy. 
Two  days  later  this  puffiness  had  largely  subsided;  and  what 
had  been  an  elevated,  indurated,  malignant-looking  zone  at  the 
edge  of  the  growth  w^as  now  quite  pink,  flat,  and  devoid  of 
malignant  appearance.  It  was  evident  that  some  material  or 
influence  had  passed  through  this  tissue,  beyond  the  line  limit- 
ing total  demtalisation,  which  zvas  suMcient  to  destroy  malig- 
nant cells  zvhile  only  acting  as  an  irritant  to  the  normal 
histologic  elements.  The  subsequent  history  of  the  case  fully 
established  the  fact  that  at  least  a  greater  portion  of  these  cells 
had  been  killed,  for  the  tissue  never  regained  its  malignant 
characters,  though  this  patient  was  finally  carried  off  by  the 
continued  progress  of  metastastic  deposits  in  various  internal 
organs  that  had  been  implanted  some  time  before  the  applica- 
tion was  made. 

The  discovery  that  pure  mercuric  ions  could  be  produced  and 
diffused  from  a  gold  instrument  was  the  result  of  subsequent 
experiment,  when  it  was  found  also  that  this  diffusion  was  so 
rapid,  by  reason  of  the  action  being  confined  to  the  mercury, 
gold  being  unattackable,  that  it  was  necessary  to  devise  some 
means  of  keeping  the  active  surface  of  gold  supplied  with  its 
mercury  coating,  even  under  a  moderate  current.  This  was 
finally  done  by  employing  tubular  instruments  made  of  pure 
18  karat  gold,  through  the  caliber  of  which  an  excess  of  the 
quicksilver  was  injected  with  a  glass  syringe  after  the  instru- 
ment was  in  position  In  the  tumor. 

Anodes  composed  of  iron,  metallic  arsenicum,  copper,  and 
of  silver — the  last  two  coated  with  mercury — have  also  been 
experimentally  used,  but  it  was  found  that  all,  except  silver, 
were  inferior  in  a  most  marked  degree  to  the  first  accidental 
combination  of  zinc  and  mercury.  The  exact  value  of  silver- 
mercury  ions  has  not  as  yet  been  determined.  \ 

General  Prognosis  of  Cancerous  Growths  under  Ionic 
Sterilization. — This  method  is  not  one  that  acts  by  produc- 
ing a  mysterious  effect  at  a  distance  through  air-space  and 
tissue,  as  in  the  case  of  Roentgen  rays,  but  a  simple  applica- 
tion of  the  laws  of  phoretic  diffusion  to  surgery,  with  possi- 
bilities only  greater  under  certain  conditions  than  the  grosser 
art  of  tissue  severance  with  the  knife.  The  results  are,  there- 
fore, due  to  the  adaptation  of  a  new  surgical  method  to  the 
varying  anatomical  problems  of  individual  growths,  and  these 


38  Destruction  by  Metallic  Ions. 

problems  have  thus  far  received  the  close  attention  of  but  a 
handful  of  operators  in  a  limited  number  of  cases,  the  latter 
often  badly  chosen  in  the  absence  of  a  clear  knowledge  of  the 
limitations  of  the  method. 

The  results  already  attained  show,  nevertheless,  that  ionic 
surgery  has  a  wide  field  of  usefulness  as  a  preferable  method 
in  the  destruction  of  incipient  growths  in  many  portions  of 
the  body,  judging  from  the  small  number  of  this  class  that  have 
been  placed  under  it.  That  the  opportunities  to  employ  it  in 
this  class  have  been  so  few  is  probably  due  to  the  general 
neglect  of  early  treatment,  added  to  which  is  the  natural  tend- 
ency of  physicians  to  turn  to  a  new  treatment  only  in  the  most 
desperate  cases,  and  after  all  other  means  have  failed. 

Cases  properly  classifiable  as  inoperable  by  the  knife  and 
by  every  other  known  method  have  therefore  been  the  main 
source  of  the  author's  material  in  the  development  of  the 
method,  many  having  been  undertaken  in  order  that  the  pa- 
tient might  have  the  benefit  of  the  doubt  that  still  surrounded 
the  possibilities  of  the  method  and  the  uncertainty  of  the  pres- 
ence of  metastasis.  Under  such  conditions  it  has  been  most 
gratifying  to  the  author,  in  reviewing  his  more  than  sixteen 
years'  work  with  the  method,  that  a  large  proportion  of  the  pa- 
tients treated  have  been  greatly  benefited;  that  a  very  small 
proportion  have  not  been  benefited  or  have  been  made  worse; 
and  that  a  few  have  had  their  lives  saved,  and  have  been  actu- 
ally cured  when  this  result  could  not  possibly  have  been  secured 
by  the  use  of  any  other  known  means. 

In  view  of  these  facts  it  is  evident  that  the  classification  of 
a  given  malignant  tumor  into  the  operable  or  inoperable  lists 
will  require  new  studies  with  ionic  surgery  available,  for  the 
possibly  operable  class  is  distinctly  enlarged  by  this  method. 

In  the  end,  it  will  be  found  that  the  most  valuable  sphere  of 
ionic  surgery  will  be  to  render  treatment  in  the  operable  stage 
more  attractive  than  it  has  been  to  the  patient  in  the  past,  and 
thus  to  induce  early  resort  to  the  surgeon ;  for  in  this  stage  it 
often  offers  a  less  fearsome  prospect  of  blood  and  mutilation, 
with  equal  or  better  prospect  of  cure. 

As  to  what  constitutes  a  cure,  great  caution  must  be  em- 
ployed. To  permit  patients  to  believe  that  a  cure  has  been 
reached  as  soon  as  the  parts  have  healed  with  no  disease  mani- 
fest is  most  dangerous  to  their  ultimate  welfare.     They  should 


Post-Operative  Inspection.  39 

be  distinctly  warned  that  it  is  their  duty  to  remain  under  regu- 
lar periodical  expert  inspection  for  at  least  three  years  before 
a  cure  can  be  affirmed,  though  freedom  from  evidence  of  a  pre- 
existent  metastasis  for  one  year  after  destruction  of  a  tumor, 
with  no  local  recurrences  ascertainable  by  expert  inspection, 
gives  reasonable  assurance  of  success. 

This  three-year  limit  for  the  development  of  latent  germs  of 
the  growth  in  the  locality  of  the  wound,  and  of  indubitable 
evidences  of  a  pre-operative  internal  metastasis,  is,  of  course, 
entirely  arbitrary  and  subject  to  occasional  exceptions.  The 
greatest  number  of  local  and  regional  recurrences  appear  in 
the  first  three  months  when  a  sharp  lookout  is  given  the  case, 
and  the  three-year  limit  means  that  each  successive  period  of 
time  is  so  increasingly  free  from  new  growth  not  observable  on 
close  inspection  in  previous  periods  of  time  as  to  reach  a  rea- 
sonable certainty  of  its  non-appearance  by  the  end  of  three 
years. 

It  is  the  author's  belief  that  there  has  been  too  little  expert 
post-operative  inspection  of  these  cases,  and  that  recurrences 
credited  to  the  end  of  one  and  two  years  could  have  been  dis- 
covered and  destroyed  within  a  few  weeks  or  months  after  the 
operation. 

So  important  is  the  need  of  mutual  attention  to  these  points 
on  the  part  of  both  surgeon  and  patient,  and  a  full  realization 
of  their  true  position  on  the  part  of  patients,  that  those  now 
discharged  in  good  condition  from  the  Oncologic  Hospital  are 
given  a  printed  slip  reading  as  follows:  "In  consideration  of 
the  absolute  need  of  full  co-operation  between  physician  and 
patient  that  the  best  results  may  be  attained  in  treatment,  I 
hereby  promise  that  when  discharged  from  the  hospital  in  good 
condition  I  will  present  myself  to  the  surgeon  in  charge  of  my 
case,  or  to  his  delegated  representative,  at  periods  not  less  than 
three  months  apart  for  three  years,  and  that  if  directed  to  re- 
turn for  further  treatment  I  will  make  the  utmost  endeavor  to 
do  so." 


CHAPTER  V. 

THE    PHYSICS    OF    THE    IONIC    STERILIZATION    PROCESS,    AS    EM- 
PLOYED  IN   THE  DEVITALIZATION   OF  DISEASE   AREAS. 

A  dear  conception  of  the  electro-chemical  reactions  occur- 
ring in  living  tissues  during  the  employment  of  the  method 
described  in  the  preceding  chapter  requires  some  attention  to 
the  phenomena  of  electrolysis.  These  phenomena  are  under 
very  active  study  at  the  present  time,  both  from  theoretical  and 
practical  points  of  view.  The  theoretical  aspects  of  the  sub- 
ject have  been  studied  anew,  since  1887,  by  Van't  Hoff,  of 
the  University  of  Berlin,  and  by  Arrhenius,  a  Swedish  physi- 
cist, resulting  in  entirely  new  conceptions  of  electrolysis  and 
its  correlative  sequences :  anaphoresis  and  cataphoresis.  The 
practical  aspects  of  the  subject  have  been  even  more  compre- 
hensively developed  in  the  immense  strides  made  in  the  manu- 
facture of  synthetic  compounds  and  electrolytically  separated 
chemicals  in  Germany  and  at  Niagara  Falls,  at  the  latter  place 
the  current  from  the  great  power  plant  being  untilized  for  the 
purpose. 

The  basis  of  the  method  employed  in  the  ionic  steriliza- 
tion of  diseased  foci  is  the  fact  that  the  living  tissues,  partic- 
ularly the  highly  cellular  and  vascular  growths  under  consid- 
eration, are  made  up  of  various  salts  in  organic  combinations 
held  in  solution  in  water.  The  large  proportion  of  water 
present  is  shown  by  the  fact  that,  by  weight,  the  soft  parts 
are  three-quarters  water  and  but  one-quarter  solids. 

Now,  these  newer  facts  of  electro-chemistry  teach  us  that 
when  a  salt  is  in  solution  in  water  it  is,  in  a  sense,  no  longer 
a  salt  as  we  know  a  salt  in  the  dry  state,  but  an  ionized  solu- 
tion of  the  atoms  of  which  it  is  composed.  That  is :  that  the 
molecules  of  chloride  of  sodium,  for  instance,  are  largely  dis- 
sociated when  in  solution  in  water,  the  atoms  of  chlorine  and 
sodium,  as  well  as  most  of  the  component  atoms  of  the  water 
molecules  themselves,  being  no  longer  simple  atoms,  but,  by/ 
reason  of  possessing  an  electric  charge,  ions.  The  hydrogen 
of  the  water  and  the  sodium  of  the  NaCl  possess  a  positive 

40 


Polar  Reactions.  41 

charge,  and  hence  tend  to  seek  the  negative  pole  if  a  current 
of  electricity  traverses  the  compound ;  they  are  therefore  called 
cations.  The  oxygen  of  the  water  and  the  chlorine  of  the 
NaCl  possess  a  negative  charge,  and  are  hence  anions,  or  anode 
seekers.  Whether  a  current  of  electricity  is  passing  through 
such  a  solution  or  not,  this  dissociated  or  ionized  condition  of 
salts  and  most  acids  and  bases  exists  whenever  they  are  in 
solution  in  that  great  solvent,  water,  without  which  neither 
chemical  action  nor  life  itself  could  continue.  Such  solutions 
are  known  as  electrolytes. 

Water  itself  is  but  slightly  dissociated  or  ionized  unless  it 
contains  a  trace  at  least  of  some  one  of  these  substances; 
therefore  pure  water  will  not  conduct  electricity,  since  it  is  the 
ions  alone  that  conduct  this  force.  As  a  side  remark,  it  may 
be  said  here  that  watery  solutions  of  many  substances  do  not 
conduct  electricity  because  these  substances  are  not  ionized  by 
this  solvent.* 

To  return  to  the  question  at  issue :  AVhen  a  current  is 
passed  through  the  ionized  or  dissociated  body  of  molecules 
constituting  the  basal  constituents  of  a  living  growth,  a  power- 
ful directing  movement  is  given  to  the  ions  everywhere  pres- 
ent, the  oxygen,  chlorine  and  other  anions  being  impelled 
toward  the  anode  (the  active  electrode,  or  electrode  within  the 
growth),  where  they  give  up  their  —  charge,  becoming  simple 
atoms.  These  atoms,  no  longer  in  the  condition  of  ions,  at- 
tack the  least  refractory  elements  of  opposite  sign  at  hand, 
in  this  case  the  mercury  and  zinc  of  the  electrode,  or  the 
mercury  alone  if  it  is  held  in  place  by  a  gold  electrode,  forming 
oxides  and  chlorides  of  the  metals.  These  metals  being  now 
in  solution  in  water  and  thus  ionized,  are  but  lightly  held 
by  the  oxygen  and  chlorine,  and  being  themselves  charged  with 
-\-  electricity,  become  cations,  seeking  at  once  the  negative 
pole  on  a  distant  portion  of  the  body.  The  released  oxygen 
and  chlorine  remain  near  the  active  electrode,  forming  water, 
hydroxyl  and  other  compounds,  while  the  mercury  and  zinc 
ions  radiate  outwards,  uniting  and  dis-uniting  in  turn  with 
the  oxygen  and  chlorine  of  the  tissues  as  they  spread,  destroy- 
ing the  vitality  of  cells  and  germs  as  they  proceed,  since  zinc 

*  An  instance  of  this  is  sugar,  a  solution  of  which  in  water  will 
neither  conduct  nor  be  electrolyzed  by  an  electric  current,  showing  the 
low  value  of  this  substance  in  the  life  chemistry  of  the  body. 


42  Physics  of  the  Ionic  Process. 

and  mercury  in  the  ionized  state  are  poisonous  to  protoplasm. 
As  their  progress  is  relatively  slow  they  do  not  reach  a  great 
distance,  betraying  their  course  by  a  characteristic  grayish 
white  necrosis  wherever  sufficiently  dense  to  do  so. 

The  exact  nature  of  the  diffused  salts  has  been  determined 
by  Gautier,  of  France,  with  reference  to  copper,  which  was 
found  diffused  as  both  oxides  and  chlorides  when  living  ani- 
mals were  subjected  to  the  process.  That  there  is  an  abundance 
of  combined  oxygen  for  these  purposes  in  the  soft  tissues  of 
the  cancer  is  shown  when  we  remember  that  y2  per  cent,  of 
the  body  as  a  whole  is  composed  of  oxygen  (Marshall). 

Turning  to  the  reactions  simultaneously  occurring  at  the 
negative  pole,  resting  in  good,  moist  contact  with  a  distant 
portion  of  the  body  surface,  it  should  be  noted  that  an  exactly 
equal  amount  of  electro-chemical  change  occurs  here,  though 
of  opposite  sign,  hence  this  electrode  contact  must  be  very 
large  in  order  that  the  reactions,  by  being  spread  over  a  great 
surface,  may  not  do  more  than  stimulate  the  skin  and  under- 
lying tissues.  The  cations  that  actually  reach  this  electrode 
(during  the  moderate  time  that  the  process  is  employed)  are 
the  sodium,  potassium  and  other  bases  of  the  nearby  tissues, 
which,  approaching  the  tin  plate  as  cations,  give  up  their 
charge  and  lose  themselves  as  atoms  of  these  bases  in  the 
abundant  water  of  the  large  pad  interposed  between  the  tin 
plate  and  the  body  surface,  the  water  itself  being  dissociated 
into  oxygen  and  hydrogen.  Of  this  dissociated  water  the 
oxygen  is  diffused  inwards  into  the  body  as  an  anion  while 
the  hydrogen  appears  free  as  a  gas.  The  only  real  accumu- 
lation of  cations  in  the  pad,  of  any  moment,  are  therefore 
the  free  alkaline  bases,  and  these  do  no  harm  to  the  skin  if 
the  pad  is  thick  and  sufficiently  broad. 

The  interpolar  tissues  of  the  general  body  traversed  by  the 
current  suffer  no  change,  other  than  a  general  quickening  of 
the  chemical  processes. 

Recurring  to  the  electrochemical  changes  at  the  site  of 
ionic  diffusion  within  the  growth,  the  anodic  region  of  the 
body  electrolyte,  it  should  be  said  that  the  nearer  a  given 
cell  or  germ  lies  to  the  electrode  the  denser  will  be  the  flow 
through  it  of  the  zinc-mercury  ions,  resulting  in  more  cer- 
tain destruction.  In  the  actual  conditions  encountered  in 
practice — the  use  of  a  third  of  an  ampere  to  one  ampere  dur- 


Cataphoric  Speed  of  Ions.  43 

ing  a  time  varying  from  a  half-hour  to  one  hour — the  steriliz- 
ing cations  never  reach  the  relatively  distant  cathode  on  the 
patient's  back.  The  most  distant  are  probably  but  one  or  two 
inches  (three  to  five  centimeters)  beyond  the  point  where 
their  density  ceases  to  devitaHze  all  the  tissues  (at  which  point 
the  line  of  demarcation  will  develop  several  days  later).  It 
is  in  this  wider  circle  of  less  dense  diffusion  that  the  purer 
effects  of  reaction  without  necrosis  occur,  the  lowly  con- 
stituted malignant  cells  being  destroyed  alone  for  probably 
a  half  cm.  beyond  the  point  of  total  destruction,  while  a  por- 
tion at  least  of  the  normal  cells  are  only  subjected  to  a  strong 
irritation. 

The  speed  at  which  these  mercury  and  zinc  ions  are  made 
to  traverse  the  tissues  has  not  yet  been  accurately  determined, 
but  is  dependent  on  the  voltage  of  the  current,  the  amount 
transferred  being  dependent  on  the  amperage.  Kohlrausch 
discovered  that  each  ion  has  its  own  rate  of  motion  in  a 
given  liquid,  independently  of  what  it  may  happen  to  have 
been  combined  with,  hydrogen  traveling  faster  than  any  other 
ion.  Lodge  *  gives  the  subjoined  table  of  the  speed  of  ions 
of  the  substances  mentioned  when  urged  by  a  potential  of  one 
volt  per  lineal  centimeter  of  electrolyte. 

Table  of  Cataphoric  Speed  of  Ions  at  One  Volt  per  Centimeter. 

Hydrogen    1.080  centimeters  per  hour. 

Potassium 0.205  centimeter  per  hour. 

Sodium   0.926 

Lithium    0.946 

Silver 0.166 

Carbon 0.213 

Iodine    0.216 

The  two  substances  in  which  we  are  most  interested,  mer- 
cury and  zinc,  are  unfortunately  not  mentioned  in  this  table, 
though  all  ions  probably  have  a  rate  bearing  some  relation 
to  their  combining  equivalents,  as  suggested  by  Prof.  Dolbear 
in  a  conversation  with  the  author.  This  question  is  one  of 
great  importance  in  the  clinic  room,  and  so  far  as  concerns 
mercury,  it  may  be  roughly  said  that  5  grains  (1-3  gram)  of 
metallic  mercury  will  be  diffused  one  centimeter  into  the  flesh 

*  "Modern   Views  of  Electricity,"   Lodge,   p.   87. 


44  Physics  of  the  Ionic  Process. 

by  a  current  of  50  milliamperes  at  50  volts  in  ten  minutes. 
By  doubling-  the  voltage  the  same  current  should  transfer  a 
similar  amount  of  mercury  twice  the  distance  in  the  same  time. 
If  these  figures  are  only  approximately  correct  it  will  be  seen 
that  not  only  are  currents  of  large  volume  required  in  this 
work,  but  they  must  be  at  a  sufficient  pressure  and  maintained 
long  enough  for  the  lethal  material  to  reach  the  outlying  por- 
tions of  the  growth,  and  particularly  the  branch-like  prolonga- 
tions. The  completeness  of  the  protoplasmic  devitalization  is 
due  to  the  density  of  the  current,  it  is  true,  but  no  matter  how 
densely  a  strong  current  may  diffuse  the  medicament,  a 
sufficient  time  must  be  allowed  for  its  due  penetration,  and  the 
prompt  devitalization  of  the  affected  cells  in  the  more  distant 
portions  of  the  growth.  This  may  be  assisted  at  times  by  the 
use  of  more  than  one  active  electrode;  in  fact  this  should 
invariably  be  done  in  the  larger  growths,  in  order  that  the 
time  in  which  the  patient  is  kept  under  anesthesia  be  less- 
ened, but  it  should  not  be  forgotten  that  each  additional  active 
electrode  will  necessitate  a  corresponding  increase  in  the  cur- 
rent to  keep  the  local  action  of  each  electrode  up  to  a  prop- 
erly effective  concentration.  Two  electrodes  will  require  twice 
as  much  current  as  one,  and  three  will  require  three  times  as 
much. 

The  use  of  too  many  electrodes,  or  of  a  broad,  active  surface 
pressed  against  an  ulceration,  has  the  disadvantage  of  either 
dividing  up  the  current  into  ineffective  portions,  resulting  in 
a  lack  of  concentrated  action,  or  of  requiring  more  current 
than  convenient  to  make  each  effective.  The  author's  ex- 
perience has  shown  also,  that  a  moderate  amount  of  the  ions 
inserted  beneath  the  surface,  directly  amongst  the  cells,  by 
means  of  a  puncturing  electrode,  is  more  effective  than  much 
more  material  diffused  from  a  broad  electrode  placed  against 
the  surface. 

Experimental  Demonstration  of  Mercuric  Diffusion 
WITHIN  Flesh. — To  demonstrate  the  diffusion  of  mercury  ions 
within  beef  is  both  interesting  and  easy.  The  piece  of  beef  should. 
be  of  sufficient  size,  fresh,  and  preferably  made  up  of  muscular 
tissue  or  other  non-fatty  parts.  It  should  be  laid  on  a  porce- 
lain dish  or  other  non-conducting  surface,  and  a  metallic  in- 
strument of  any  metal  thrust  into  one  end  connected  with  the 
negative  cord  of  the  battery.     The  active  electrode  must  be 


Experimental  Demonstration  of  Mercuric  Diffusion,     45 

of  gold,  well  amalgamated  with  mercury,  and  after  it  is  thrust 
into  the  opposite  end  of  the  beef  an  additional  supply  of  mer- 
cury should,  be  poured  or  dropped  on  it  so  that  it  will  not  be- 
come bared  by  the  action  of  the  current. 

From  five  hundred  to  one   thousand  milliamperes   should 
now  be  turned  on  from  an  appropriate  source  and  maintained 
about  fifteen  minutes.     The  meat  nearest  the  anode  will  be 
seen  to  change  color  at  once,  very  much  as  in  living  flesh, 
the  discoloration  radiating  in  all  directions  from  the  electrode 
but  mainly  towards  the  opposite  pole.     When  sufficient  effect 
has  been  obtained  the  current  is  turned  off  and  a  longitudinal 
section  of  the  meat  is  made,  passing  through  the  points  at 
which  the  electrodes  were  inserted.    The  extent  and  effect  of 
the  diffused  chemicals  can  then  be  easily  traced,  so  far  as  these 
can  be  shown  in  dead  flesh.    The  limits  of  the  area  of  steriliza- 
tion can  be  easily  made  out,  shading  off  into  unchanged  sur- 
rounding flesh,  but  the  zone  of  infiltration-reaction,  as  it  would 
be  in  living  tissues,  can  only  be  traced  in  part  by  the  discolora- 
tion produced  by  the  chemicals.     To  discern  what  would  be 
its  extent  the  following  expedient  may  be  employed :    Remove 
the  electrodes  and  cords  from  the  battery  and  connect  a  pair 
of  copper  wires  to  the  binding  posts  of  the  battery,  the  wires 
being  bared  and  brightened  at  their  ends.     With  the  same 
amount    of    current    turned    fully    on    these    wires    (500    to 
1000  ma.),  their  ends  should  be  held  about  a  centimeter  apart 
and  pressed  into  the  beef  for  some  moments  at  various  points, 
beginning  near  the  negative  polar  region  and  gradually  work- 
ing towards  the  positive  polar  region.    As  soon  as  a  portion 
of  the  meat  is  reached  holding  the  mercuric  salts,  even  though 
in  insufficient  quantity  to  cause  discoloration  of  the  meat,  there 
will  be  a  deposit  of  metallic  mercury  on  the  negative  copper 
wire,  shown  even  in  small  quantity  by  the  silver  color  of  this 
wire  compared  with  its  fellow,  and  proving  the  extensive  pen- 
etration of  the  chemical. 


CHAPTER  VI. 

SELECTION    AND    INSTALLATION    OF    APPARATUS    REQUIRED    FOR 
IONIC  SURGERY. 

Source  of  Current. — Careful  consideration  must  be  given  to 
the  current  source  in  the  major  operation  of  zinc-mercuric 
ionization,  employing  as  it  does  from  300  to  1500  milli- 
amperes,  or  even  more,  during  a  continuous  application  ex- 
tending from  fifteen  minutes  to  an  hour  or  more.  All  of  the 
old-fashioned  batteries  were  grievous  failures  in  the  author's 
earlier  work,  the  most  painstaking  care  being  insufficient  to 
prevent  faults  and  failures  even  after  a  patient  was  under  the 
anesthetic.  The  current  mains  of  an  incandescent  lighting  sys- 
tem are  the  best  possible  source  of  power  for  this  work,  and 
if  the  system  is  one  employing  the  no  volt  direct  current  a 
suitable  controller  and  meter  are  the  only  applying  apparatus 
needed. 

If  the  street  mains  at  hand  furnish  the  alternating  current, 
as  is  generally  the  case  in  the  smaller  towns  and  cities,  it  will 
be  necessary  to  procure  also  a  motor  transformer  to  transform 
the  alternating  current  into  the  direct  current  of  the  voltage 
mentioned. 

Should  neither  form  of  current  be  available,  as  in  towns 
without  an  electric  lighting  system  or  at  isolated  residences, 
ample  power  may  be  obtained  from  40  to  60  freshly  manufac- 
tured dry  cells  of  approved  make,  and  these  may  often  be 
depended  on  to  do  full  work  for  several  months. 

Direct  Current  Mains. — Having  a  direct  current  supply  of 
no  volts  which  is  steady  and  reliable  during  the  hours  for  this 
work,  the  current  may  be  taken  from  any  lamp  receptacle  by 
substituting  a  plug  to  which  is  attached  a  double  conducting 
cord  leading  to  the  controller.  At  the  first  use  of  any  partic- 
ular receptacle  or  socket  the  polarity  of  the  conducting  cords 
should  be  ascertained  as  follows:  Before  inserting  the  plug 
into  the  socket  unwind  two  or  three  inches  (5  or  6  centimeters) 
of  the  end  of  the  cord,  bare  the  end  of  each  wire,  and  bend 
them  apart  so  that  they  will  not  come  into  accidental  contact- 

46 


Alternating  Current  Mains. 


47 


now  insert  the  plug  into  the  receptacle  and  turn  on  the  cur- 
rent if  there  be  a  key  for  this  purpose,  then  insert  both  wire 
ends  in  water  in  which  a  little  salt  has  been  dissolved.  The 
active  decomposition  of  the  water  that  results  at  once  will 
show  that  one  wire  gives  off  twice  as  much  gas  as  the  other; 
this  wire  is  therefore  of  course  the  negative  pole,  and  should 
be  so  marked  as  soon  as  the  current  is  turned  off,  a  bit  of 


Fig.  2. — Motor-Transformer  of  Holtzer-Cabot  Type,  suitable  for  ionic 
surgery  and  other  electrotherapeutic  work. 

adhesive  plaster  with  an  N  marked  on  it  in  ink  being  a  perma- 
nent mark  when  twisted  about  the  wire.  The  polarity  of  these 
wires  should  be  tested  anew  whenever  a  new  receptacle  is 
used. 

Having  ascertained  and  marked  the  polarity  of  each  wire, 
they  are  inserted  in  the  P  and  N  inlet  posts  of  the  special 
controller  described  below,  or  into  the  appropriate  inlet  posts 
of  the  ionization  table.  The  wires  should  be  left  permanently 
attached  to  the  latter,  disconnection  being  made  by  removing 
the  plug  from  the  receptacle. 

Alternating  Current  Mains. — To  transform  the  alternating 
current  to  the  no  volt  direct  current  a  motor  transformer  is 
employed.  This  consists  of  a  one-half  horsepower  alternating 
current  motor,  suitable  to  the  phase  and  number  of  alternations 
of  the  local  system,  and  a  2}^  ampere  no  volt  direct  current 


48 


Selection  of  Apparatus. 


dynamo  coupled  directly  together  and  mounted  on  the  same 
base  (Fig.  2).  A  snap  switch  in  the  leads  from  the  mains 
enables  the  apparatus  to  be  started  and  stoppe'd  with  ease. 
The  dynamo  is  usually  supplied  with  a  rheostat  placed  in 
circuit  with  the  field  winding.  This  enables  us  to  vary  the 
voltage  of  the  output  somewhat,  and  is  a  useful  auxiliary  to  the 
therapeutic  controller.     In  the   Holtzer-Cabot   apparatus   the 

TREATMENT  MAINS. 


TO  RHEOSTAT. 

Fig.  3. — Diagram  of  Connections  on  Dynamo  Portion  of  Motor-Trans- 
former, to   show  proper  connections. 


current  for  treatment  is  taken  from  the  dynamo  at  the  poles 
indicated  in  the  diagram,  Fig.  3,  and  the  polarity  is  ascertained 
in  the  manner  described  in  the  paragraph  relating  to  the  direct 
current. 

The  current  as  taken  from  the  dynamo  is  exactly  similar  to 
that  from  the  no  volt  direct  current  street  mains.  It  is,  how- 
ever, unnecessary  to  have  a  dynamo  give  an  output  greater 
than  two  and  a  half  amperes  (2500  milliamperes),  as  this  size 
of  dynamo  will  fully  cover  the  needs  of  ionization  work. 

Dry  Cells. — As  before  stated,  a  battery  of  freshly  manufac- 
tured commercial  dry  cells  of  ordinary  size  and  reliable  make 
furnishes  a  possible  means  of  power  for  the  performance  of  a 
number  of  major  operations.  From  40  to  60  are  necessary, 
and  if  these  are  assembled  in  portable  boxes  of  strong  build 
we  are  enabled  to  perform  major  operations  at  any  point 
within  reach  of  the  railroads  or  other  means  of  transportation, 
the  applying  mechanism  described  below  being  also  portable. 
The  author  has  traveled  thousands  of  miles  with  such  an  out- 


Dry  Cells. 


49 


fit,  keeping  a  sharp  eye  on  the  battery  boxes  at  every  change 
of  baggage  car,  the  apparatus  being  ready  for  action  within 
a  few  minutes  of  its  arrival  at  the  residence  of  the  patient  or 
the  local  hospital.  These  battery  boxes  may  be  supplied  with 
a  switchboard  as  in  Fig.  4,  or  with  two  simple  binding  posts 


Fig.  4. — Portable  Dry  Cell  Battery  with  Switchboard. 


to  each  box,  to  one  of  which  a  wire  is  led  from  the  carbon 
pole  to  the  first  cell.  From  the  zinc  pole  of  this  cell  a  wire 
is  led  to  the  carbon  pole  of  the  next,  and  so  on,  the  final 
zinc  pole  being  connected  with  the  other  binding  post  of  the 
battery  box.  The  binding  posts  of  the  box  should  now  be 
each  marked  with  their  appropriate  signs. 

When  the  batteries  are  to  be  used  the  N  post  of  the  first 
box  is  connected  by  wire  with  the  P  post  of  the  second ;  the 
N  post  of  the  first  box  and  the  P  post  of  the  second  then  being 
the  final  poles  of  the  battery.  From  these  posts  wires  are 
carried  to  the  controller  as  described  for  the  direct  current  of 
the  street  mains. 

An  automobilist's  pocket  ammeter  is  useful  to  detect  any 


50  Selection  of  Apparatus. 

weakening  of  these  cells.  The  voltage  is  maintained  in  these 
cells  near  the  1.4  volts  per  cell  longer  than  the  amperage, 
which  should  not  fall  below  8  or  10  amperes  when  short- 
circuited  through  these  small  ammeters.  If  any  cell  falls  below 
5  amperes  it  should  be  thrown  out  before  an  operation 
is.  attempted. 

No  other  form  of  primary  cell  than  a  good  commercial  dry 


Fig.  5. — Portable  Dry  Cell  Battery  with  Switchboard  Raised,  showing- 
connections. 

cell  should  be  used  for  this  purpose.  Storage  cells  would,  of 
course,  be  an  excellent  source  of  power,  but  the  large  number 
of  these  heavy  cells  needed  to  obtain  the  voltage  required 
makes  it  impossible  to  employ  this  source  of  current  in  a  port- 
able apparatus. 

Control  of  Current. — Cataphoric  diffusion  of  ionized  sub- 
stances is  accomplished  by  the  continuous  flow  of  a  direct  cur- 
rent of  sufficient  volume,  even  in  the  heaviest  major  applica- 
tions, and  there  is  therefore  no  need  and  no  excuse  for  shocks 
due  to  rapid  variation  of  the  current.  All  sudden  variations 
or  interruptions  of  the  current  are  to  be  carefully  guarded 
against.  The  only  certain  way  to  avoid  shocks  is  the  use  of 
an  efficient  graphite  controller  of  the  type  long  known  as  the 


Control  of  Current. 


51 


Massey  graphite  controller.  The  standard  instruments  of  this 
type  are,  however,  too  small  to  control  currents  over  250 
milliamperes  in  strength.  For  currents  over  250  milliamperes 
we  must  employ  the  enlarged  Universal  Graphite  Controller 
first  described  in  a  recent  edition  of  a  work  by  the  author.* 


Fig.  6. — Pocket  Ammeter. 

This  instrument  (Fig.  7)  is  manufactured  by  Williams,  Brown 
&  Earle  of  Philadelphia,  and  the  Frank  S.  Betz  Co.  of  Ham- 
mond, Ind.  It  will  permit  a  current  to  be  turned  on  in  the  most 
gradual  manner  from  zero  to  2000  milliamperes,  and  is  there- 
fore not  only  necessary  in  the  work  under  consideration  but 
fills  all  the  purposes  of  a  controller  for  lesser  currents,  both 
constant  and  induced,  in  ordinary  office  practice.  It  is  some- 
what unwieldy  as  a  portable  instrument,  but  can  be  readily 
transported  when  supplied  by  the  manufacturer  with  a  suitable 
case. 

This  latest  and  most  perfect  graphite  controller  has  been 
made  much  larger  than  the  standard  instruments  of  the  last 
ten  years  to  adapt  it  for  the  control  of  the  heavy  currents  of 

*  "  Conservative  G3-necolog3^  and  Electro-Therapeutics,"  by  G.  Betton 
Massey,  M.D.,  Sixth  Edition,  F.  A.  Davis  Co.,  Philadelphia,  Pa.,  1909. 
The  author  is  now  experimenting  with  wire  controllers. 


52 


Selection  of  Apparatus. 


a  major  ionic  application,  yet  if  the  graphite  coating  at  the 
"start"  is  sufficiently  light  the  initial  increase  of  the  current 
as  it  is  turned  on  is  quite  gradual. 

A  further  development  of  this  instrument,  made  possible  by- 
its  ample  size,  is  such  an  arrangement  of  the  circuits  traversing 


Fig.  7.— Masse}'  Universal  Graphite  Controller.  The  lamp  to  the  left 
is  the  series  resistance  lamp;  that  to  the  right,  the  shunt  lamp. 
Both  lamps  should  be  used  in  minor  applications.  In  major  opera- 
tions both  are  cut  out,  or  turned  off. 


it  as  will  transform  it  at  the  will  of  the  operator  into  a  more 
delicate  controller  of  weak  currents  than  even  the  small  con- 
trollers. This  is  done  by  cutting  down  the  amperage  delivered 
to  it  from  the  mains  by  inserting  a  series  lamp  (see  Figs.  8 
and  9)  between  the  controller  and  the  mains,  and  a  shunt  lamp 
(also  shown  in  Figs.  8  and  9)  parallel  with  the  patient,  but 
not  in  the  meter  circuit.  The  result  of  placing  this  shunt  lamp 
parallel  with  the  patient  is  the  division  of  the  current  delivered 


Tlie  Controller 


53 


by  the  controller  between  the  lamp  and  the  patient,  and  as 
even  a  i6  candlepower  lamp  presents  far  less  resistance  than 
the  tissues  of  the  patient,  under  the  usual  circumstances,  the 
bulk  of  the  current  traverses  the  lamp  and  a  lesser  amount  the 


Series  Lamr 


Fig.  8. — Plan  of  wiring  of  Universal  Therapeutic  Controller. 

patient,  thus  permitting  of  a  most  delicate  graduation  of  a 
minor  current  and  its  most  gradual  "turn  on,"  thus  minimiz- 
ing pain. 

A  necessary  result  of  this  division  of  current  between  two 
paths  is  the  division  of  the  voltage  equitably  between  them.^ 
The  use  of  such  a  shunt  constitutes  the  instrument  therefore 


54 


Selection  of  Apparatus. 


a  volt  controller  as  well  as  a  milliampere  controller.  It  is 
well  known  that  a  control  of  voltage  is  most  desirable  when 
making  minor  applications  in  painful  situations — that  2  mil- 
liamperes,  for  instance,  is  less  painful  from  4  volts  than  from 
the  whole  voltage  of  the  no  volt  circuit. 


^DYNAMO 


Fig.  9. — Diagram  of  several  paths  or  "  shunts  '•'  of  the  circuit  of  Uni- 
versal Graphite  Controller.  The  size  of  the  arrows  shows  approxi- 
mateh-  the  relative  proportions  of  the  current  in  the  several  paths, 
though  this  varies  with  kind  of  application.  (The  cut  should  show 
the  meter  in  the  "  patient "  shunt.) 

Besides  filling  the  absolute  necessities  of  a  controller  for 
heavy  currents,  it  will  therefore  be  seen  that  this  instrument. 
has  valuable  qualities  as  a  general  controller  of  therapeutic 
currents,  and  especially  the  more  delicate  applications  of 
ionization  to  painful  localities. 

This  controller  is  adapted  to  be  used  with  a  battery  of  dry 
cells  exactly  as  with  the  current  of  the  mains.     By  throwing 


The  Controller. 


55 


a  portion  of  the  work  on  all  the  cells  equally  it  conserves  their 
life  and  causes  equality  of  wear,  as  compared  with  the  old- 
fashioned  cell  collector,  while  its  gradual  variation  of  the  cur- 
rent makes  it  as  essential  when  employing  cells  as  when  using 
the  mains.     To  use  the  shunt  lamp  with  cells  is  nevertheless 


Fig.  10. — Massey  Type  Weston  Milliampere  Meter.  The  divisions  of 
the  scale  may  be  seen  some  yards  from  instrument,  and  extend,  on 
the  two  scales,  from  o  to  lOO  and  o  to  2000  milliamperes,  being 
capable  of  being  read  to  1-2  milliampere.  To  select  scale  place  plug 
in  appropriate  socket  shown  in  lower  portion  of  cut. 


a  severe  strain  on  their  lasting  qualities.  When  not  in  use  this 
controller  should  always  be  cut  off  from  the  cells  by  opening 
a  double  knife  switch. 


56  Selection  of  Apparatus. 

In  using  this  instrument  with  the  no  volt  current  the  fol- 
lowing variations  are  possible,  giving  great  range  to  its  capa- 
bilities for  heavy  or  fine  work: 

I.  With  both  lamps  turned  off,  or  "out"  of  circuit,  it  is 
adapted  to  control  the  full  1 10  volts  by  mere  variation  of  resist- 
ance to  produce  currents  var}'-ing  from  o  to  2000  milliamperes. 
This  adapts  it  to  heavy  current  work,  and  also  for  the  control 
of  induction  currents. 

2.  With  the  series  lamp,  which  is  usually  placed  at  the  left, 
turned  "in"  and  the  shnnt  lamp  turned  "out"  of  circuit,  the 
apparatus  is  more  safely  placed  in  the  hands  of  inexpert  per- 
sons, as  the  amount  of  current  delivered  through  it  by  acci- 
dental short  circuit  is  limited  by  the  resistance  of  the  lamp. 
This  amount  may  be  varied  by  using  a  16  C.  P.  lamp  for 
lesser  currents  and  a  32  or  50  C.  P.  lamp  for  greater  currents. 
The  use  of  this  series  lamp  adapts  the  controller  particularly 
for  the  delivery  of  gynecological  currents  from  the  mains,  with 
a  range  of  variation  from  o  to  250  milliamperes.  The  series 
lamp  should  not  be  used  when  employing  a  batter}^  of  dry  cells,^ 
or  with  the  induced  currents. 

3.  With  both  the  series  and  shunt  lamps  turned  "in"  circuit 
it  is  adapted  to  control  the  voltage  as  well  as  milliamperage, 
giving  a  less  painful  current  for  the  finer  work,  such  as  minor 
applications  of  zinc-mercury  ionization  and  electrolysis,  epila- 
tion, etc.,  and  with  the  lamps  in  this  position  the  controller  will 
light  4  and  6  volt  lamps  safely  from  the  no  volt  current. 

Measurement  of  Current. — The  development  of  heavy  cur- 
rent work  in  the  ionic  treatment  of  cancer  made  the  use  of 
a  meter  of  higher  range  than  usual  imperative.  That  such  a 
meter  should  be  reliable  w^as  also  absolutely  essential,  particu- 
larly when  investigation  revealed  a  most  disgraceful  lack  of 
reliability  among  the  meters  sold  to  physicians. 

As  a  result,  the  author  employed  at  first  a  specially  ordered 
portable  Weston  meter,  w'ith  two  scales : — o  to  1000  milliam- 
peres and  o  to  2000  milliamperes.  This  instrument,  while 
reliable,  has  still  been  under  the  disadvantage  of  having  to  be 
specially  ordered  when  wanted.  Further  experience  showed, 
also,  that  the  scale  and  index  of  this  portable  instrument  were 
too  small  to  be  easily  seen  by  the  operator  standing  or  sitting 
several  yards  away,  and  that  the  lower  scale  was  not  high 
enough  for  minor  ionic  work. 


Fig.  II. — Ionization  Table,  an  aseptic,  movable  mounting  of  the  Au- 
thor's Controller  and  Meter,  With  multiple-attachment  binding  post 
for  the  active  electrodes.  Designed  for  both  major  and  minor 
applications. 


58  Selection  of  Apparatus. 

The  Weston  Electrical  Instrument  Co.  of  Waverly  Park, 
N.  J.,  was  therefore  induced  to  construct  and  place  on  the 
market  at  a  moderate  price,  an  instrument  designed  by  the 
author  to  meet  these  objections  (shown  in  Fig.  lo).  This 
meter  can  be  confidently  recommended  as  specially  adapted  to 
both  major  and  minor  ionization  applications.  As  its  im- 
proved features  are  equally  valuable  in  other  applications  of 
the  constant  current,  this  meter  should  be  preferred  to  other 
styles  in  stationary  apparatus  of  all  kinds,  such  as  the  Ioniza- 
tion Table,  Wall  Plates  and  Cabinets,  and  may  be  specially 
arranged  for  portability,  if  desired,  though  somewhat  large  for 
this  purpose. 

The  scales  of  this  meter  are  about  seven  inches  long,  giv- 
ing great  range,  and  the  index  may  be  seen  across  the  room. 
In  spite  of  this  large  size  of  the  index,  however,  currents  on 
the  lower  scale,  which  reads  from  o  to  lOO  in  single  milliam- 
peres,  mayi  be  read  to  one-half  milliampere,  and  the  increase 
to  the  maximum  is  most  gradual.  On  the  upper  scale,  which 
reads  from  o  to  2000  milliamperes,  each  division  of  the  scale 
has  the  value  of  20  milliamperes,  but  considerable  space  is  al- 
lotted to  each  hundred,  permitting  the  turning  on  of  a  heavy 
current  to  be  quite  gradual. 

The  Ionization  Table. — The  desirability  of  having  all  the 
furniture  in  a  modern  operating  room  aseptic,  simple,  and  free 
from  wood  or  other  absorbent  material,  induced  the  author  to 
design  the  current  applying  table  shown  in  Fig.  11,  for  use 
in  the  electrical  operating  room  of  the  Oncologic  Hospital. 

The  table  is  constructed  of  white  enameled  iron  and  has 
a  top  of  extra  heavy  glass  with  an  ordinary  glass  shelf  be- 
neath. On  the  top  plate  a  Universal  Controller  is  mounted 
directly  on  the  glass,  with  all  connections  beneath.  In  front 
of  the  controller  there  is  ample  space  for  the  glass  tray  con- 
taining the  mercury,  acid,  and  water  glasses,  the  active  elec- 
trodes, etc.  The  meter  is  mounted  on  a  brass  arm  fixed  at  an 
angle  above  the  controller,  and  capable  of  being  seen  by  the 
operator  at  any  position.  The  two  binding  posts  are  on  the 
front  of  the  table,  mounted  on  the  glass  plate,  and  a  special 
feature  is  that  the  two  poles  are  permanently  designated  by 
dififerently-appearing  posts,  the  positive  having  five  binding 
screws  for  attachment  of  as  many  wires  leading  to  active  elec- 
trodes, and  the  negative  two  binding  screws  for  attachment  of 


Fig.  12. — Rear  view  of  Ionization  Table,  showing  switches  for  using 
series  and  shunt  lamps  in  minor  applications. 


6o  Selection  of  Apparatus. 

wires  leading  to  the  pad  or  the  bipolar  negative  electrode  at 
will. 

Fig.  12  shows  a  rear  view  of  the  Ionization  Table,  with  the 
fiber  plate,  on  the  inner  side  of  which  the  series  and  shunt 
lamps  are  attached.  The  lamps  project  under  the  top  plate 
of  the  table  well  out  of  the.  way,  while  the  switches  for  throw- 
ing them  "in"  or  "out"  are  accessible  from  the  rear  of  the  table. 
Just  above  this  switchboard  are  the  inlet  binding  posts  of  the 
table,  to  which  the  cords  from  a  lamp  socket  or  batter}^  of 
cells  are  attached. 

"With  both  lamp  switches  turned  to  "  in,"  and  the  plug  be- 
neath the  meter  in  the  "loo"  socket,  the  apparatus  is  ready  for 
minor  applications.  With  both  switches  turned  to  "out"  and 
the  plug  in  the  "2000"  socket,  it  is  ready  for  a  major  applica- 
tion. 

The  table  may  be  used  with  the  direct  current  of  the  mains, 
the  transformed  direct  current  from  alternating  current  mains, 
or  with  a  battery  of  cells.  It  is  furnished  by  Williams,  Brown 
&  Earle,  Philadelphia. 

The  Indifferent  Pole  Dispersing  Pad. — The  indifferent  or  dis- 
persing pole  in  a  cataphoric  operation  or  application  is  of 
course  always  connected  with  the  negative  pole  of  the  appara- 
tus, and  when  the  application  is  a  minor  one  it  may  consist 
of  any  good  dispersing  pad,  such  as  those  suitable  in  electro- 
gynecology.  For  the  heavy  current  of  a  major  monopolar 
operation  a  much  larger  dispersing  pad  is  required  to  render 
this  pole  free  from  more  local  action  than  a  mere  reddening 
of  the  skin.  If  this  pad  be  too  small,  or  so  improperly  ar- 
ranged as  to  permit  unequal  dispersion  of  the  current  over 
the  skin  surface,  alkaline  eschars  will  form  in  the  skin  at  this 
situation  that  are  slow  to  heal  and  give  the  patient  much  dis- 
comfort. 

After  experiment  with  various  materials  the  author  has 
settled  upon  kaolin  pads  as  in  .every  way  the  best,  this  ma- 
terial being  preferred  as  possessing  the  qualities  of  fine  pul- 
verization and  neutral  chemical  reaction  that  best  adapt  it  to 
ph3^sically  absorb  the  alkaline  chemicals  that  appear  at  this 
pole,  as  well  as  freedom  from  the  possibility  of  staining  white 
clothing.  The  intimate  contact  secured  by  all  clay  electrodes 
with  the  minute  inequalities  of  the  skin,  thus  broadening  the 
area  of  practical  contact  between  the  skin  and  the  electrode. 


The  Dispersing  Pad.  6i 

is  of  course  the  chief  value  of  this  form  of  electrode.  Kaolin 
is  at  present  largely  employed  medically  as  the  base  of 
glycerine-bearing  poultices.* 

For  convenience  of  handling,  the  kaolin  is  inclosed  in  flat 
bags  made  of  crash  toweling,  and  two  such  pads  are  usually 


Fig.  13. — Kaolin  Pads  of  various  sizes,  for  use  as  Dispersing  Electrode. 
The  thin  metal  plate  is  shown  on  one. 

required  in  the  heaviest  operations.  Each  pad,  when  filled 
properly  with  kaolin,  should  measure  about  14  by  20  inches 
(35  by  50  centimeters),  and  possess  a  uniform  thickness  of 
one  inch  (2^  cm.).  An  additional  pad  of  oval  shape  with 
extreme  diameters  of  8  by  12  inches  (15  by  30  cm.),  and  of 
the  same  thickness,  is  a  most  useful  size  for  minor  applica- 
tions as  well  as  for  gynecological  applications. 

In  making  these  pads  the  material  is  cut  somewhat  larger 
than  necessary  and  is  securely  stitched  on  the  wrong  side, 
leaving  an  opening  in  one  end  through  which  the  kaolin 
powder  may  be  subsequently  poured,  and  is  then  turned  and 
stitched  around  the  edge,  making  what  is  called  a  '"French" 

*  Kaolin  may  be  obtained  in  suitable  quantities  from  Wm.  M.  Wil- 
son's Sons,  225  Dock  St.,  Philadelphia. 


62  Selection  of  Apparatus. 

seam.  The  dry  kaolin  is  then  poured  in  and  carefully  distrib- 
uted with  a  flat  roller  until  the  bag  is  evenly  filled  about  an 
inch  (2^  cm.)  thick.  The  opening  is  then  securely  sewn 
up.  Before  wetting  the  pad  the  upper  and  lower  surfaces 
should  be  tacked  together  at  points  about  two  inches  apart  by 


Fig.  14. — Copper  Sterilizer  with  perforated  Inner  Movable  Bottom, 
designed  for  keeping  the  kaolin  pads  warm,  moist,  and  clean. 
Length  20  inches,  width  14  inches,  depth  7  inches. 

passing  the  needle  through  and  through,  for  the  purpose  of 
keeping  the  pad  of  a  uniform  thickness  throughout. 

The  completed  pads  are  kept  permanently  immersed  in  water 
in  a  copper  sterilizer  of  proper  size  possessing  a  perforated 
copper  tray  supported  on  short  legs,  permitting  circulation 
of  water  beneath  the  pads  (Fig.  14).  Before  use  the  sterilizer 
is  placed  on  a  gas,  electric,  or  other  heater  and  warmed  to  a 
proper  temperature.  If  the  water  within  the  sterilizer  is  occa- 
sionally brought  to  the  boiling  point  the  pads  are  kept  fresh 
and  clean. 

Pads  thus  made  and  kept  continually  wet  are  always  soft 
and  pliant,  and  the  heaviest  currents  may  be  passed  through 
them  for  long  periods  without  harm  to  the  skin.  One  of  the 
large  pads  with  its  metal  backing  is  sufficient  for  500  to  600 
milHamperes  when  appplied  to  a  broad  skin  surface,  such  as 
that  of  the  back,  but  if  a  stronger  current  is  to  be  applied 
for  a  long  period  both  pads  should  be  used,  placed  sidewise, 
and  the  wires  connected  with  the  metal  plates  should  be  car- 
ried together  to  the  negative  binding  post  of  the  apparatus. 

Beneath  the  pad,  furthest  from  the  skin,  a  metal  plate  is 
placed.  This  plate  is  best  made  of  thin  alloy,  such  as  is  now 
largely  employed  as  a  protection  in  x-ray  applications.  The 
metal  plate  should  be  absoluteh^  pliant  and  smooth,  about  two 


Plate  I. — Pope-Massey  Special  Wall  Plate,  with  Weston  Meter.     This  apparatus 
can  be  employed  in  major  and  minor  ionic  applications.      (Frank  S.  Betz  Co.) 


64  Selection  of  Apparatus. 

inches  (5  cm.)  less  in  both  diameters  than  the  pad,  and 
should  be  connected  with  the  negative  binding  post  by  a  suf- 
ficient length  of  No.  26  copper  wire,  the  wire  being  attached 
to  the  plate  by  threading  it,  duly  bared,  through  some  holes  in 
the  corner  of  the  plate,  and  wrapping  the  plate  over  it  sev- 
eral times.  Care  should  be  observed  to  cover  this  connection 
between  the  wire  and  plate  with  a  small  piece  of  rubber  cloth 
before  laying  the  pad  upon  it,  as  otherwise  the  current  may 
short-circuit  from  the  thinly  covered  wire  through  this  portion 
of  the  pad  directly  to  the  patient. 

The  detailed  method  of  placing  this  pad  for  an  operation 
will  be  found  in  the  next  chapter. 

The  Active  Electrodes. — In  the  development  of  the  ioniza- 
tion treatment  of  cancer  the  author  was  accidentally  led  to 
employ  zinc  coated  with  mercury  as  the  material  for  the  sol- 
uble electrodes.  It  was  later  found  that  pure  mercury  could 
be  diffused  as  an  ion  from  -electrodes  of  pure,  or  18  karat, 
gold,  the  mercury  being  temporarily  united  with  the  gold  by 
amalgamation,  and  that  with  heavy  currents  the  mercury 
would  disappear  so  rapidly  from  the  gold  instrument  that  pro- 
vision had  to  be  made  for  an  extra  supply  by  injecting  it  into 
the  tissues  in  immediate  contact  with  the  instrument  through 
a  tunnel  in  the  latter.  The  gold  was  never  acted  upon  itself 
by  the  current,  and  when  the  supply  of  mercury  and  the  alloys 
in  the  gold  were  diffused  it  remained  as  an  unattackable 
electrode. 

Comparative  tests  of  pure  mercuric  ionization  from  these 
gold  electrodes  and  of  the  mixed  zinc-and-mercury  ioniza- 
tion from  pointed  zinc  instruments  showed  later,  neverthe- 
less, that  the  latter  were  more  effective  in  necrosing  results 
and  equally  good  in  sterilization.  The  pointed  zinc  instrument 
merely  coated  with  mercury  was  also  a  more  controllable 
instrument  than  the  pointed  cannulas  of  gold,  which  required 
the  presence  of  additional  liquid  mercury,  the  latter  being  kept 
in  the  place  desired  only  with  much  difficulty  at  times.  The 
result  has  been  that  the  zinc-mercury  instruments  are  exclu- 
sively employed  at  present.* 

Minor     Application     Electrodes. — The     minor     electrodes, 

*  For  a  description  and  illustration  of  the  gold-mercury  electrodes 
see  the  author's  work  "Conservative  Gynecology  and  Electro-Thera- 
peutics," Sixth  edition,  F.  A.  Davis  Co.,  Philadelphia,  1909,  p.  218. 


Plate  II. — Author's   Ionic  Switchboard  with  author's  type  of   J\leter, 
as  made  by  Williams,  Brown  &  Earle  of  Philadelphia. 


66  Selection  of  Apparatus. 

shown  in  the  upper  portion  of  Fig.  15,  are  furnished  in  sample 
only  by  the  manufacturers,  as  they  are  readily  made  by  the 
surgeon  or  an  assistant,  and  the  shape  and  length  are  largely 
determined  by  the  particular  case,  or  even  the  stage  of  the 
case,  in  which  they  are  used.  These  electrodes  are  also  those 
that  are  advised  in  the  treatment  of  tubercular  glands  of  the 
neck  or  other  accessible  tubercular  cavities  or  nodules. 

The  electrode  is  cut  from  sheet  zinc  of  a  thickness  of  1-64 
inch  (approximately  j4  millimeter),  being  the  thickness  largely 
used  beneath  stoves,  etc.  A  long-handled  pair  of  surgical  scis- 
sors enables  the  metal  to  be  cut  easily  into  slivers,  though  tin- 
ners' shears  of  superior  steel  are  better,  the  slivers  being  about 
1%  inch  (4^  centimeters)  long  and  }i  inch  (4  milli- 
meters) wide  at  the  butt  end,  tapering  to  a  fine  point,  well 
sharpened  by  jfiling.  A  suitable  length  of  No.  32  cotton- 
covered  copper  wire  is  then  prepared  to  act  as  the  conductor 
for  the  current  by  baring  a  short  portion  at  each  end.  One 
bared  end  of  this  wire  is  wrapped  tightly  about  the  butt  of 
the  electrode  and  clamped  firmly  in  place  by  turning  the  end 
of  the  electrode  over  it  with  a  pair  of  pliers.  The  instrument 
is  then  complete  as  an  uninsulated,  or  No.  i,  minor  electrode. 
Immediately  before  insertion  into  the  growth  the  active  tip  is 
amalgamated  by  dipping  it  for  an  instant  in  weak  sulphuric 
acid,  into  metallic  mercury,  and  into  plain  water,  in  turn. 

The  No.  2  minor  electrode  is  a  similar  instrument  coated 
with  insulating  wax  except  at  its  tip.  This  is  done  by  gently 
heating  it  over  a  Bunsen  burner  or  alcohol  lamp  and  at  the 
same  time  melting  the  end  of  a  stick  of  sealing-wax  and  fusing 
the  latter  in  an  even  coat  over  the  non-active  portions  of  the 
electrode.  The  result  is  an  exceedingly  delicate  instrument 
for  applications  beneath  non-diseased  edges  and  in  cavities, 
the  insulation  limiting  action  to  the  part  desired. 

The  fine  wire  advised  as  a  conductor  of  the  current  is  se- 
lected for  mechanical  reasons,  such  as  the  dragging  weight 
of  a  heavy  wire  on  the  electrode,  the  instrument  itself  being  too 
light  for  the  heavier  conductor.  Its  conducting  power  is  more 
than  ample  for  any  currents  capable  of  being  employed  with 
these  electrodes.  A  further  precaution  to  insure  against  the 
added  pain  caused  by  any  motion  of  the  instrument  from  acci- 
dental movements  of  the  patient  is  the  expedient  of  applying 
a  steadying  guy  to  the  wire  near  its  attachment  to  theelec- 


Fig.  15. — Author's  Zinc-Mercury  Cancer  Electrodes  (one-half  natural 
size).  A.  No.  i,  Alinor  electrode.  B.  No.  2,  Minor  electrode. 
C.  Leash  of  medium-size  external  electrodes.  D.  Minor  mouth, 
uterine  or  rectal  electrode,  uninsulated.  E.  ]\Iajor  breast  or  external 
electrode.  F.  and  G.  Major  mouth,  uterine,  or  rectal  electrodes. 
H.  Spade-pointed  major  uterine  or  rectal  electrode.  (Procurable 
of  Williams,  Brown  &  Earle,  Philadelphia.) 


68  Selection  of  Apparatus. 

trode;  this  is  done  by  attaching  a  small  piece  of  adhesive 
plaster  to  the  wire  near  the  electrode,  and  sticking  the  ends 
of  the  plaster  to  the  skin  of  the  patient  in  such  a  way  that 
the  wire  will  not  touch  the  skin.  This  arrangement  will  per- 
mit the  patient  to  move  at  will  during  a  prolonged  application 
without  disarranging  the  electrode. 

These  electrodes  may  be  employed  as  multiple  points  in  a 
major  application  when  a  large  surface  of  moderate  depth  is 
to  be  sterilized.  For  this  purpose  a  leash  of  conductors  is 
prepared  by  cutting  from  four  to  a  dozen  short  lengths  of  No. 
32  or  30  wire  and  attaching  their  bared  ends  to  the  bared  end 
of  a  longer  length  of  No.  26  wire,  which  is  attached  at  its 
other  end  to  the  positive  binding  post.  The  point  of  junction 
of  these  wires,  after  being  tightly  twisted,  is  carefully  insulated 
by  covering  it  with  a  small  piece  of  adhesive  plaster.  A 
dozen  such  points  can  stand  a  current  of  20  milliamperes  per 
point,  or  a  total  of,  say,  250  milliamperes,  during  a  prolonged 
application,  thus  conserving  time  in  the  treatment  of  a  broad 
surface  growth. 

The  instruments  described  above,  and  the  smaller  ones  of 
those  described  below,  should  be  used  once  only,  and  then 
discarded  as  too  brittle  for  further  work. 

External  or  Breast  Electrodes. — With  the  exception  of  the 
minor  electrodes  just  described,  the  remaining  zinc-mercury 
electrodes  are  primarily  intended  for  the  major  application, 
though  the  smallest  external  size  may  at  times  be  advan- 
tageously used  in  a  minor  one.  These  electrodes  are  made 
from  either  1-32  inch  (i  millimeter)  plate  zinc,  in  which 
case  they  may  be  cut  by  the  surgeon  or  his  assistant  by 
means  of  a  pair  of  tinner's  shears,  and  attached  to  No.  28 
wire  in  the  same  way  as  mentioned  for  the  minor  electrode ; 
or  they  may  be  made  of  still  heavier  zinc  1-16  inch  (i^  milli- 
meters) thick;  in  the  latter  case  being  procured  from  the 
manufacturers  or  other  artisan,  and  being  attached  to  No.  28 
conducting  wires  by  the  latter  being  wound  tightly  about  a 
neck  filed  near  the  butt  of  the  electrode.  In  width  these  elec- 
trodes vary  from  3-16  inch  (4  millimeters)  to  a  fine  point, 
and  in  length  from  3  to  5  inches  (8  to  12  centimeters).  It 
is  at  times  useful  to  cover  the  butt  end  of  these  electrodes 
with  fused  sealing-wax  to  protect  the  wire  joint  from  the 
action  of  the  mercury,   which  would   make  the   wire   brittle. 


Mouth  and  Throat  Electrodes.  69 

This  makes  a  convenient  handle  also.  No.  28  wire  is  the 
most  suitable  size  for  the  shorter  lengths  of  this  weight  of 
electrode.  Each  electrode  is  usually  attached  to  a  single  con- 
ducting wire,  or,  when  a  large  growth  is  to  be  attacked,  from 
two  to  six  of  the  same  length  may  be  attached  to  a  leash 
of  wires  as  described  in  the  last  paragraph.  They  should  be 
bent  to  the  curve  desired,  if  a  curved  instrument  is  needed, 
before  amalsfamation. 


Fig.  16. — Major  Uterine  Electrode,  insulated. 

Mouth  and  Throat  Electrodes. — The  longer  lengths  of  the 
electrodes  just  described  are  also  suitable  for  use  in  cavities, 
not  deeply  situated,  if  the  fused  wax  insulation  is  carried  over 
the  whole  instrument  except  the  centimeter  or  centimeter  and 
a  half  at  the  active  point.  Any  shape  desired  may  be  given 
the  instrument  before  insulating  it,  whether  curved  on  the  flat 
or  edge,  the  latter  shape  being  suggested  by  Dr.  Amedee 
Granger  of  New  Orleans,  who  points  out  that  sharply  pointed 
instruments  have  the  advantage  in  mouth  operations  of  being 
self-sustaining  when  properly  curved.  Attachment  to  the  con- 
ductor may  be  made  by  a  spring  socket,  as  in  Fig.  16,  or,  as 
more  recently  preferred  by  the  writer,  by  a  suitable  length  of 
No.  28  wire  attached  tightly  to  the  butt  by  wrapping  and 
twisting. 

Cervical  and  Rectal  Electrodes. — A  minor  application  may 
be  made  to  the  cervix  uteri  of  as  much  as  a  hundred  milliam- 
peres  by  the  use  of  an  electrode  similar  to  those  advised  for 
the  mouth  and  throat,  though  somewhat  longer,  made  of  the 
middle  thickness  of  zinc  described  above  and  properly  insu- 
lated. 

In  a  major  application  to  the  same  parts  the  active  tip  must 
be  made  larger  owing  to  the  tendency  to  overheating  when 
a  heavy  current  is  confined  to  a  small  area  of  active  surface, 
hence  the  selection  of  the  pointed,  spade-shaped  electrode 
shown  in  the  cuts  when  but  one  instrument  can  be  used  at  a 


70  Selection  of  Apparatus. 

time.     Like  all  the  instruments,  it  may  be  bent  at  any  angle 
desired  before  amalgamation. 

Insulation  of  Electrodes. — All  active  electrodes  employed 
within  cavities  should  have  those  portions  of  their  surfaces 
which  are  intended  to  be  non-active  coated  with  an  insulating 
material.  This  confines  the  whole  effect  to  the  spot  designed 
to  be  destructively  sterilized  and  protects  non-diseased  sur- 
faces from  useless  and  painful  erosion.  The  ability  to  thus 
carr}'-  the  action  to  any  spot  desired  within  a  cavity,  or,  in- 
deed, beneath  any  tissue  safely  penetrable  by  an  electrode,  is 
one  of  the  chief  advantages  of  the  ionization  method.  This 
insulation  is  best  accomplished  in  all  electrodes  not  injured  by 
heat  by  the  employment  of  sealing-wax,  a  non-conducting 
material  when  free  from  metal  coloring,  but  particularly  in 
the  instruments  under  consideration,  as  the  act  of  properly 
coating  the  heated  shank  or  non-active  parts  with  hot  wax 
not  only  secures  perfect  insulation  but  perfect  asepsis  also. 
When  so  prepared  an  instrument  capable  of  use  more  than 
once  is  rendered  perfectly  fresh  and  new  for  a  second  appli- 
cation. This  aseptic  coating  is,  moreover,  more  convenient 
in  practice  than  tube  coverings  or  other  methods  of  permanent 
insulation,  as  it  presents  no  shoulder  to  catch  in  the  tissues,  the 
melted  wax  shading  off  in  thickness  at  this  point. 

Black  sealing  wax  (Dennison's  No.  4  Black  Express  wax 
being  an  excellent  variety)  presents  a  seemly  appearance,  and 
is  readily  obtained  at  most  stationery  stores  in  convenient  and 
inexpensive  sticks  when  procured  in  pound  lots. 

To  apply  the  wax,  heat  the  electrode  over  the  flame  of  a 
Bunsen  burner  or  alcohol  lamp — very  gently  if  a  minor  elec- 
trode is  to  be  coated,  as  zinc  readily  burns — and  when  it  is 
hot,  melt  the  end  of  the  stick  of  wax  in  the  flame  and  bring 
the  surfaces  together :  a  small  portion  of  hot  wax  will  adhere 
to  the  instrument.  Apply  other  portions  similarly  to  various 
surfaces  and  edges,  and  gently  reheat  the  electrode  until  the 
'Gating  is  even,  smooth,  and  complete.  It  is  often  necessary 
to  retouch  the  shank  of  the  instrument  in  order  to  cover  the 
sharp  edges  which  the  hot  wax  is  liable  to  leave.  A  little  prac- 
tice soon  leads  to  expertness,  and  one  can  readily  coat  a  long 
and  slender  instrument,  such  as  required  in  the  nostril,  for 
instance,  with  great  ease. 

An  instrument  capable  of  being  used  more  than  once  re- 


Amalgamation  of  Electrodes. 


71 


quires  a  fresh  insulation,  which  also  asepticizes  it  before 
being  used  on  a  second  case.  All  necessary  changes  in  curve 
should  be  given  the  electrode  before  insulation. 

Amalgamation. — The  amalgamation  of  an  electrode  is  the 
union  of  metallic  mercury  with  it  at  its  active  surface.     The 

Batteries 


Fig.   17. — Diagram  of  arrangement  of  Portable  Apparatus   for  mono- 
polar ionic  operation. 

mercury  unites  with  the  metal  to  some  distance  beneath  the 
surface,  and  as  this  renders  the  zinc  quite  brittle,  the  electrode 
should  not  he  amalgamated  until  it  has  been  curved  and  in- 
sulated and  the  patient  is  ready  for  the  operation.  Metallic 
mercury  unites  with  a  bright,  clean  zinc  surface  as  soon  as 


^2  Selection  of  Apparatus. 

the  latter  is  dipped  into  it.  As  the  average  electrode  tip  is 
slightly  tarnished  by  oxidation,  however,  it  is  most  convenient 
to  dip  it  into  a  dilute  solution  (25  to  50  per  cent.)  of  sulphuric 
acid.  If  it  is  then  dipped  into  the  mercury  the  maximum 
amount  of  the  latter  will  adhere  to  it,  particularly  if  alterna- 
tively dipped  into  dilute  acid,  mercury,  plain  water,  and  into 
mercury  again ;  ending  up  with  a  final  dipping  into  water  to 
remove  any  remaining  acid. 

A  necessary  adjunct  to  the  operating  table  will  therefore  be 
a  glass  tray  on  which  are  placed  three  glass  receptacles,  con- 
taining, respectively,  dilute  sulphuric  acid,  metallic  mercury, 
and  water.  For  the  smaller  electrodes  and  the  tips  of  the 
internal  electrodes  ordinary  medicine  glasses  make  excellent 
containers  of  these  materials.  When  a  long  breast  instrument 
is  to  be  amalgamated  slender  vessels  about  10  centimeters 
high,  with  bases  to  keep  them  upright,  such  as  are  used  with 
urinometers,  are  most  convenient. 

Arrangement  of  Portable  Apparatus  for  Major  Operation. — 
In  a  major  operation  with  portable  apparatus  the  battery 
boxes,  containing  from'  30  to  60  commercial  dry  cells,  are  con- 
nected to  the  controller  as  shown  in  Fig.  17.  The  batteries 
being  properly  connected  up,  the  meter  is  put  in  circuit  by  con- 
necting its  -f-  post  with  the  P  treatment  post  of  the  controller. 

The  dispersing  pad  is  now  connected  by  its  wire  with  tfie 
N  treatment  post  of  the  controller  and  the  active  electrodes 
with  the  free  binding  post  of  the  meter. 

In  using  this  portable  apparatus  with  the  no  volt  direct 
current  the  polarity  of  the  wires  attached  to  the  plug  is  ascer- 
tained as  described  above,  and  the  proper  wires  attached  to 
the  P  and  N  inlet  posts  of  the  controller,  the  remaining  con- 
nections being  made  as  just  described. 


CHAPTER  VII. 

OPERATIVE  DETAILS  OF  IONIC  APPLICATIONS. 

The  author's  personal  experience  in  the  ionic  treatment 
of  malignant  growths,  together  with  that  of  his  colleagues 
using  this  method  in  the  Oncologic  Hospital,  has  indicated  the 
desirability  of  varying  the  nature  of  the  operation  in  certain 
cases  by  varying  the  position  of  the  negative  pole.  In  the 
operation  chiefly  referred  to  in  the  preceding  pages,  the  large 
dispersing  pad  constitutes  the  negative  pole,  and  is  usually 
placed  beneath  the  patient's  back,  or,  at  times,  on  the  thighs. 
The  end  in  view  is  the  removal  of  this  pole  as  far  as  possible 
from  the  active  electrodes,  in  order  that  the  ions  diffused  from 
the  latter  will  penetrate  deeply  towards  the  base  and  periphery 
of  the  growth.  Such  penetration  of  the  ions  occurs  in  the 
lines  of  current  flow,  of  course,  and  this  means  in  large 
growths  the  inward  transmission  of  a  considerable  bulk  of 
current  that  must  pass  through  neighboring  nervous  and  mus- 
cular structures  before  it  is  widely  dispersed,  with  the  risk  of 
temporarily  tetanizing  muscular  structure  and  inhibiting  nerve 
action.  More  than  an  amount  suitable  to  a  minor  application 
is,  therefore,  to  be  avoided  when  the  heart  lies  directly  beneath, 
as  in  operations  on  the  left  breast;  when  important  nerves  in 
the  neck  lie  close;  or  when  such  a  current  must  traverse  the 
brain  structures  with  the  active  electrodes  in  the  orbit.  This 
difficulty  may  be  generally  avoided  by  abandoning  this  monopo- 
lar method  in  major  operations  in  such  cases  and  using  the 
bipolar  method,  in  which  the  negative  pole  is  placed  on  or 
in  the  center  of  the  growth  itself,  the  active,  positive  electrodes 
being  thrust  into  the  periphery  of  the  growth.  Effective  work 
may  be  accomplished  by  this  bipolar  method,  though  possibly 
at  times  inferior  to  that  done  by  the  monopolar,  for  the  ions 
will  be  dispersed  to  some  extent  from  all  sides  of  the  active 
electrodes,  fairly  sterilizing  the  periphery  of  the  growth,  while 
its  center  succumbs  to  the  simple  electrolytic  action  of  the 
negative  pole. 

73 


74  Operative  Details. 

OPERATIVE  TECHNIC  OF   MAJOR   MONOPOLAR  OPERATION. 

The  propriety  of  general  anesthesia  having  been  determined 
by  examinations  of  the  urine,  the  blood,  and  the  condition  of 
the  arteries,  the  patient  is  prepared  for  anesthesia  the  night 
before  the  operation  by  the  administration  of  a  saline  laxative, 
and  is  directed  to  eat  no  breakfast  on  the  morning  of  the  opera- 
tion, or  a  light  breakfast  and  no  lunch  if  the  operation  is  to 
be  performed  in  the  afternoon.  No  local  preparation  of  the 
growth  itself  is  necessary,  though  an  aseptic  condition  of  the 
surrounding  skin  surfaces  is  best  secured  by  applying  a  moist 
antiseptic  compress  for  six  or  eight  hours  previous  to  the 
operation  in  purulent  cases.  Elaborate  scrubbing  of  the 
growth  should  be  interdicted  as  unnecessary  and  liable  to  cause 
metastasis  by  forcing  malignant  cells  into  the  lymphatic  or 
general  circulation. 

Before  beginning  the  administration  of  the  anesthetic  all 
preparations  of  the  apparatus  for  the  operation  should  be  com- 
pleted. If  portable  apparatus  is  to  be  used,  it  is  brought  into 
the  operating  room  and  connected  up  as  described  in  Chapter 
VI.  If  the  Ionization  Table  is  to  be  used,  it  is  merely  placed 
in  proper  position  with  reference  to  the  part  of  the  body  to 
be  operated  on.  When  any  doubt  exists  as  to  whether  the 
current  will  pass  freely  through  the  apparatus,  it  should  be 
tested  by  connecting  the  final  poles  directly  with  a  wire,  turn- 
ing the  current  on  at  the  controller,  and  noting  the  deflection 
of  the  meter  index;  but  if  this  is  done  the  controller  handle 
should  be  turned  back  at  once  to  prevent  the  possibility  of  an 
involuntary  shock  to  the  patient  subsequently. 

The  active  electrodes  should  now  be  selected  and  prepared, 
if  this  has  not  been  already  done.  Each  electrode  or  leash  of 
electrodes  should  be  laid  separately  on  a  tray  placed  on  the 
ionization  table  or  on  a  side  table  alongside  the  operating 
table,  with  their  wires  separately  coiled  and  their  ends  attached 
to  the  one  treatment  binding  post,  ready  for  instant  use  at 
any  time  during  the  operation  without  interruption  of  the 
current.  All  electrodes  liable  to  be  used  during  the  operation 
should  be  attached  to  this  binding  post  before  the  operation 
is  begun,  unless  the  Ionization  Table  is  used,  with  its  special 
facilities  for  multiple  attachments. 

Having  the  apparatus  in  readiness,  the  operating  table  is 


Major  Monopolar  Application.  75 

prepared  for  the  dispersing  pad  by  placing  a  blanket  on  it, 
folded  to  serve  as  a  cushion,  over  which  is  laid  a  waterproof 
sheet.  On  the  sheet  is  placed  the  metal  plate  with  wire  at- 
tached, and  over  the  point  of  attachment  of  the  wire  (which 
should  be  firmly  connected  to  the  plate)  is  laid  a  small  piece 
of  rubber  sheeting  to  cover  the  wire  as  it  lies  beneath  the  edge 
of  the  kaolin  pad.  The  plate  is  now  ready  for  the  warm  pad 
to  be  placed  on  it,  the  pad  meantime  having  been  left  in  the 
sterilizer,  where  it  has  been  kept  warm  and  moist  until  the 
patient  has  been  so  far  anesthetized  as  to  be  ready  to  be  placed 
on  the  table. 

The  proper  dispositions  having  been  made  and  the  patient 
anesthetized,  the  pad  is  placed  on  the  plate  and  smoothed 
with  a  rolling  pin  to  a  uniform  thickness.  The  patient  is 
now  placed  on  the  table  with  the  pad  beneath  his  back,  and 
the  proper  coaptation  of  the  pad  and  the  patient's  back  is  noted, 
care  being  observed  that  no  portion  of  the  metal  plate  comes 
in  contact  with  the  skin.  In  large  operations  two  pads  should 
be  used,  the  wires  from  both  pads  being  attached  to  the  nega- 
tive binding  post,  or  else  a  large  kaolin  mattress  may  be  used 
to  render  the  dispersion  of  the  current  as  great  as  possible  at 
this  point. 

If  a  microscopic  examination  of  the  tissue  is  to  be  made, 
it  is  necessary  to  remove  the  specimen  before  beginning  the 
operation,  as  the  action  of  the  chemicals  will  render  an  exami- 
nation impossible  later.  Aside  from  this  necessity  the  opera- 
tion is   usually   bloodless. 

With  everything  in  readiness,  the  electrodes  are  freely  amal- 
gamated and  one  is  inserted  directly  into  the  periphery  of 
the  growth  by  simple  pressure,  the  sharp  points  of  the  elec- 
trodes making  this  easy  in  spite  of  the  brittleness  produced  by 
the  mercury.  The  handle  of  the  controller  is  then  moved 
slowly  until  50  milliamperes  is  shown  by  the  meter.  This 
amount  is  gradually  increased,  while  the  tolerance  of  the  pa- 
tient is  tested  by  constant  observation  of  the  pulse  and  respira- 
tion, until  150  milliamperes  is  reached.  At  this  early  stage 
any  intolerance  is  a  mere  pain  reaction  under  a  moderate  stage 
of  anesthesia.  If  more  electrodes  are  to  be  used  another  is 
now  inserted  and  the  current  increased,  additional  electrodes 
being  inserted  as  the  increased  current  warrants;  it  being  re- 
membered that  effective  work  cannot  usually  be  done  when 


yd  Operative  Details. 

emplo3ang  the  major  size  of  electrode  with  less  than  loo  to 
150  milliamperes  per  point. 

As  the  phenomena  described  in  Chapter  V.  develop,  the 
electrodes  that  seem  to  have  accomplished  their  purpose  are 
removed,  one  at  a  time,  re-amalgamated,  and  inserted  at  fresh 
points.  In  this  way  the  whole  of  the  growth  is  gradually 
brought  under  the  influence  of  the  diffused  ions,  while  a  proper 
concentration  is  maintained. 

In  a  period  of  time,  varying  from  twenty  minutes  to  an 
hour,  in  accordance  with  the  size  and  situation  of  the  growth 
and  with  proper  placement  of  the  electrodes,  the  whole  of 
the  apparent  limits  of  the  diseased  tissues  will  be  included  in 
the  area  of  necrosis.  The  completeness  of  this  effect  can  be 
ascertained  by  both  sight  and  touch,  the  change  of  color  to  a 
whitish  gray  being  absolute.  The  change  to  touch — a  distinct 
softening  of  the  brawny  induration — is  particularly  valuable 
in  situations  where  inspection  by  sight  is  difficult,  as  in  the 
vagina  and  rectum,  though  this  change  is  a  valuable  test  in 
growths  in  any  situation.  All  evident  extensions  of  the  disease 
should  be  included  in  the  area  of  necrosis  if  possible,  the  sur- 
rounding zone  of  tissue  reaction  being  depended  on  for  the 
destruction  of  the  non-evident  prolongations  only. 

In  external  growths  special  attention  is  paid  to  the  periphery, 
particularly  that  portion  extending  toward  the  situation  of 
possibly  infected  glands.  Enlarged  glands  should  be  attacked 
at  the  outset  of  the  application  and  the  intervening  tissues 
usually  destroyed  also,  as  the  possible  lurking  place  of  infected 
cells. 

When  the  application  is  made  to  the  head,  neck,  or  near  the 
heart,  the  pulse  and  respiration  need  special  attention,  as  large 
currents  tend  to  depress  both  of  these  vital  functions.  Should 
irregular  action  be  observed,  an  immediate  turning  down  of  the 
current,  without  unnecessary  suddenness,  will  cause  an  instant 
revival  of  both  force  and  regularity.  In  fact,  though  the 
steady  action  ^f  a  heavy  current  is  a  depressant,  the  act  of 
turning  it  off  is  a  most  valuable  stimulant  to  the  vital  func- 
tions when  depressed  by  the  anesthetic  alone.  This  is  owing 
to  the  well-known  fact  that  nerve  and  muscle  respond  to  any 
change  in  the  volume  of  a  current  traversing  them,  whether 
an  increase  or  decrease,  rendering  an  ionic  operation  safer 
in    this    respect    than    other    operations,    aside     from    simi- 


Maximum  Currents  in  Monopolar  Operation.  yy 

lar    advantages    of    conservation    of    blood    and    absence    of 
shock. 

As  to  the  proper  current  strengths  to  be  employed,  mucft 
will  depend  on  the  condition  of  the  patient,  but  more  on  the 
location  of  the  growth.  The  author's  personal  experience  indi- 
cates that  the  following  amounts  may  be  safely  employed  in 
the  several  situations  mentioned,  growths  too  large  to  be 
necrosed  quickly  by  these  currents  requiring  either  that  the 
current  be  continued  for  a  sufficient  time  to  obtain  a  full 
effect,  or  that  the  monopolar  method  be  changed  where  possi- 
ble to  the  bipolar  method,  with  which  much  stronger  currents 
may  be  used : 

Maximum  Currents  Safely  Applied  by  the  Monopolar  Method. 

To  the  Head,  Mouth,  Throat,  and  Neck.  ,  .  .300  to  400  ma. 
To  the  Left  Breast  .  .  .Minor  monopolar  applications  only. 
To  the  Right  Breast  and  Thorax  generally,  400  to  800  ma. 
Below  the  Waist 800  to  1,600  ma. 

Special  procedures  relating  to  the  insulation  of  electrodes, 
and  cooling  the  site  of  application  when  necessary  in  applica- 
tions within  contracted  cavities,  will  be  found  in  the  chapters 
devoted  to  the  destruction  of  malignant  tumors  within  the 
vagina  and  rectum. 

The  proper  effect  having  been  gained  after  an  appropriate 
current-strength  and  duration,  the  current  is  slowly  turned  off 
finally,  the  electrodes  removed,  and  a  dry  sterile  dressing 
applied. 

OPERATIVE    TECHNIC    OF    MAJOR    BIPOLAR    OPERATION. 

The  term  "  bipolar  operation  "  is  employed  to  designate  a 
major  application  in  which  the  negative  pole  is  applied  on  the 
center  of  the  growth,  while  the  active,  positive  electrodes  are 
inserted  either  just  beyond  the  periphery  of  the  growth  or  as 
close  to  it  as  possible.  This  expedient,  while  inferior  to  the 
monopolar  application  in  the  production  of  the  zone  of  reaction, 
permits  the  employment  of  much  stronger  currents  in  the 
necrosis  of  large  growths  of  the  head,  neck,  and  left  breast. 
Since  weaker  lines  of  current-flow  curve  backward  from  the 
active  electrodes  in  wide  curves,  as  shown  in  Fig.  18,  in  addi- 
tion to  the  stronger  and  direct  lines  between  the  electrodes,  a 


y8  Operative  Details. 

slight  zone  of  reaction  may  be  secured  on  the  distal  sides  of 
the  active  electrodes. 

As  it  is  often  wise  to  end  a  bipolar  operation  with  a  weaker 
monopolar  current  to  increase  the  extent  of  the  zone  of  reac- 
tion, the  patient  is  placed  on  the  pad  as  described  above,  but 
the  wire  leading  from  the  pad  is  not  connected  at  first  with 
the  negative  binding  post.       Instead,  a  bipolar  negative  elec- 


FiG.    i8. — Diagram   of   cataphoric   and   anaphoric  zones  in  bipolar 

operation. 

trode  (described  below)  is  connected  with  the  negative  bind- 
ing post  by  means  of  a  piece  of  No.  26  wire. 

Bipolar  Negative  Electrode. — When  first  employing  this 
method  the  author  used  an  old-fashioned  disk  electrode  held 
against  the  center  of  the  growth  by  a  nurse.  This  was  found 
to  have  two  disadvantages :  In  a  heavy  application  the  flow  of 
hydrogen-laden,  alkaline,  frothy  liquid  is  so  great  as  to  obscure 
the  work  and  even  to  scald  healthy  skin  on  which  it  might 
flow.  The  fixation  of  the  electrode  in  its  soapy  situation  was, 
moreover,  uncertain,  particularly  when  the  attention  of  the 
nurse  wandered. 

For  external  applications,  therefore,  the  self-retaining, 
cation-absorbing,  negative  electrode  shown  in  Figs.  19  and 
20  was  devised.     This  is  conveniently  made  of  either  of  the 


Bipolar  Negative  Electrode. 


79 


thinner  sheets  of  zinc  of  which  minor  electrodes  are  made 
(the  nature  of  the  metal  being,  of  course,  indifferent,  as  the 
negative  pole  will  not  drive  metals  inward),  by  cutting  out 
with  a  pair  of  shears  a  piece  shaped  as  shown  in  Fig.  19  and 
of  a   size   suitable   to  the  growth  to  be  destroyed.     This  is 


Fia    19. — Diagram    of    piece    of    plate    zinc    used    in    making    Bipolar 
Negative  Electrode. 

curved  to  form  a  spiral  at  the  larger  end,  the  shank  being 
then  bent  to  the  exaggerated  resemblance  of  a  spoon.  Fig.  20, 
but  with  the  edge  of  the  spiral  pointing  downwards,  to  be 
placed  in  contact  with  the  center  of  the  growth.  After  attach- 
ing the  conducting  cord  to  the  small  tip  at  the  opposite  end, 
the  shank  is  completely  and  heavily  insulated  by  covering  it 
with  melted  sealing  wax.  A  strip  of  thick  gauze  is  now  in- 
serted between  the  turns  of  the  spiral,  and  it  is  nearly  sat- 
urated with  a  mixture  of  equal  parts  of  sulphuric  acid  and 
water,  which,  resting  on  the  center  of  the  growth,  will  absorb 
the  cations  of  the  tissues  as  they  reach  the  electrode,  thus 
securing  a  practically  dry  application.  The  instrument  is  so 
placed  that  the  insulated  shank  will  rest  on  healthy  skin  beyond 
the  field  of  operation,  and  it  is  secured  firmly  in  place,  with 


8o  Operative  Details. 

slight  pressure  on  the  tumor,  by  means  of  strips  of  adhesive 
plaster  passing  over  both  the  end  and  the  arch  of  the  shank. 

During  a  prolonged  or  heavy  operation  the  acid  becomes 
neutralized,  shown  by  the  appearance  of  froth,  and  may  be 
added  to  the  gauze  from  time  to  time  by  means  of  a  glass 
dropper. 

Within  cavities,  if  the  growth  be  large  enough  to  make 
the  bipolar  operation  feasible,  a  spade-shaped  electrode   (Fig. 


Fig.  20. — Negative  Electrode  of  bipolar  ionic  operation  in 
external  situations. 

1 6)  may  be  prepared  to  act  as  the  negative  pole  by  covering 
it  with  cotton,  kept  moist  with  the  acid,  and  pressed  into 
the  center  of  the  growth. 

The  active  electrodes  are  similar  in  every  way  to  those 
employed  in  the  monopolar  operation  described  in  preceding 
paragraphs  and  are  used  in  a  similar  manner,  except  that 
greater  care  should  be  used  in  inserting  them  beyond  the 
periphery  of  the  growth,  if  possible,  and  that  more  of  them 
may  usually  be  employed  simultaneously  on  account  of  the 
far  greater  current  that  it  is  possible  to  use  in  a  bipolar 
application. 

About  twice  as  much  current  may  be  employed  in  the  several 
portions  of  the  body  by  the  bipolar  method  as  compared  with 


After  Care  of  Patients.  8i 

the  monopolar,  with  even  less  influence  on  the  reflex  centers, 
thus  greatly  reducing  the  time  during  which  the  patient  is 
kept  under  the   anesthetic. 

Should  it  be  thought  wise  to  follow  the  bipolar  with  the 
greater  peripheral  diffusion  of  a  moderate  monopolar  appli- 
cation, after  the  completion  of  the  former,  the  current  is  turned 
off,  the  central  negative  electrode  is  removed,  and  the  wire 
from  the  pad  connected  instead  with  the  negative  binding 
post,  a  gentle  current  being  turned  on  and  maintained  with- 
out further  increase  of  the  anesthesia. 

After  a  bipolar  operation  with  a  heavy  current,  it  should 
be  remembered  that  the  central  portion  of 'the  slough  is  simply 
necrosed  by  electrolysis,  and  is,  therefore,  more  likely  to  give 
rise  to  odor  during  separation.  The  periphery  will  show  full 
infiltration  with  the  zinc-mercury  ions. 

AFTER   CARE   OF  PATIEXTS   FOLLOWIXG  IONIC   OPERATION. 

During  Separation  of  Slough.— The  after  treatment  of  a 
patient  who  has  received  a  major  application  of  electro- 
chemical sterilization  is  extremely  simple.  Pain  is  rarely  felt 
after  emergence  from  the  anesthetic  in  large  growths,  particu- 
larly if  they  were  painful  prior  to  operation,  though'  soreness 
or  tenderness  will  last  for  several  days.  In  smaller  growths, 
where  much  of  the  chemical  effect  has  been  expended  on 
healthy  surrounding  parts,  enough  pain  may  be  experienced 
during  the  first  twenty-four  hours  to  render  a  small  dose  of 
morphia  desirable.  The  puffy  reaction  beyond  the  zone  of 
sterilization  may  also  at  times  render  cold  compresses  useful. 

The  first  dressing  may  be  left  on  for  twenty-four  or  forty- 
eight  hours,  as  the  site  of  the  application  is  dry  and  will 
remain  so  for  some  days.  The  infiltrated  ions  have  rendered 
the  field  of  operation  practically  sterile,  and  this  condition 
will  persist  for  about  fourteen  days.  During  this  time  the 
line  of  demarcation  is  in  process  of  formation,  and  the  serous 
discharge  will  later  demand  more  frequent  changes  of  the 
gauze  dressing,  even  though  no  odor  appears.  Where  the 
slough  is  large,  and  has  been  formed  from  a  growth  in  a 
necrotic  condition,  the  antiseptic  salts  may  drain  away  dur- 
ing the  third  week  in  sufficient  quantity  to  permit  a  reap- 
pearance of  a  modified  odor,  though  such  an  odor  is  never  more 
than   infinitesimal    compared   with   the   previous    emissions    of 


82  •         operative  Details. 

an  ulcerated  growth.  To  prevent  this  reappearance  of  odor  in 
such  a  case  it  may  be  well  to  cover  the  crust  with  a  powder 
made  of  one  dram  of  carbolic  acid  rubbed  up  with  a  quarter 
of  a  pound  of  powdered  oxide  of  zinc,  or  the  devitalized  part 
may  be  kept  covered  with  a  moist  bichlorid  dressing-. 

The  slough  will  separate  spontaneously  on  or  about  the 
2ist  day,  if  the  growth  was  external  and  largely  fibrous,  or 
from  the  7th  to  the  14th  day,  if  the  growth  was  soft  and  com- 
posed mainly  of  the  neoplastic  cells.  When  bony  structure 
has  been  invaded  by  the  growth  it  is  a  participant  in  the 
necrosing  effects  and  will  separate  from  the  healthy  bone  also 
spontaneously  in  from  13  to  26  weeks.  When  the  slough  is 
large,  whether  of  soft  parts  or  bone,  it  may  harbor  germs 
of  decomposition  by  re-infection  during  the  latter  portion  of 
these  periods,  after  the  deposited  chemicals  have  in  part 
drained  away,  and  it  may,  therefore,  be  wise  to  cut  away  the 
greater  portion  of  the  slough  before  it  separates,  for  the  pa- 
tient's greater  comfort,  but  in  no  case  should  the  natural  line 
of  demarcation  be  interfered  with,  the  cutting  being  done  in 
the  dead  tissue  only. 

Secondary  Hemorrhage. — In  those  growths  where  the  line 
of  separation  forms  early  and  occurs  in  highly  vascular  tissue, 
and  particularly  when  it  occurs  in  diseased  tissue  as  a  result 
of  incomplete  operation,  there  is  some  danger  of  secondary 
hemorrhage  at  this  time,  due  to  incomplete  closure  of  the 
vessels.  This  may  be  said  to  be  almost  the  only  danger 
attending  ionization  operations,  and  it  is  best  prevented  in 
certain  localities,  particularly  in  large  carcinomas  of  the  upper 
or  lower  jaw,  by  subjecting  the  patient  to  the  operation  of 
ligation  of  the  main  arter}^  supplying  the  part,  the  opera- 
tion being  performed  about  two  wrecks  before  the  carcinoma  is 
destroyed  by  ionization  and  being  done  in  healthy  tissue; 
though  at  times  both  operations  may  be  done  seriatim,  with 
the  one  anesthesia.  This  precaution  is  seldom  required  outside 
the  localities  mentioned,  however,  the  time  required  for  the 
physiologic  separation  of  the  slough  being  usually  sufficient 
for  the  spontaneous  closure  of  the  smaller  vessels. 

In  cases  where  more  or  less  hemorrhage  is  feared  on  ac- 
count of  the  probable  inclusion  of  vessels  abnormally  enlarged 
in  the  neoplastic  growth,  a  careful  watch  should  be  main- 
tained  on   the   patient   from   the   7th   to   the    i6th   day   after 


Secondary  Hemorrhage.  83 

operation,  or  until  separation  has  occurred,  the  patient  being 
meantime  kept  at  rest  in  bed,  and  no  traction  should  be  made 
on  the  slough  until  the  vessels  have  been  occluded  by  the  nat- 
ural process.  Should  this  rare  accident  occur,  nevertheless, 
the  best  treatment  is  the  immediate  application  of  a  bichlorid 
compress  of  sufficient  thickness  to  exert  firm  pressure  on  the 
bleeding  vessel  when  held  in  place  by  a  tight  bandage.  When 
the  bleeding  is  thus  controlled  the  compress  should  be  allowed 
to  remain  in  place  for  several  days.  If  the  site  of  the  hemor- 
rhage be  within  a  cavity,  such  as  the  mouth  or  rectum,  a  small 
quantity  of  Monsell's  Solution,  to  which  3  per  cent,  of  carbolic 
acid  has  been  added,  should  be  applied  to  the  bleeding  point 
with  a  glass  syringe  or  on  pledgets  of  cotton,  and  allowed  to 
remain  for  several  days. 

After  Separation  of  Slough. — When  the  slough  of  an  exter- 
nal wound  has  separated  spontaneously,  or  by  the  final  clip- 
ping of  devitalized  fibers,  a  painless  excavation  is  revealed  in 
which  granulation  should  be  fostered  and  stimulated,  with 
such  exclusion  of  foreign  germs  as  is  possible  without  inter- 
ference with  the  granulation  process.  Such  a  surface  does 
not  heal  kindly  under  granulation-destroying  dry  gauze,  even 
if  the  gauze  is  scrupulously  sterile,  while  antiseptic  solutions 
are  equally  irritating.  The  author  has  found,  after  much 
experience,  that  the  best  dressing  for  the  wound  at  this  stage 
is  a  mixture  of  equal  parts  of  zinc-oxide  ointment  and  vaseline. 
This  exerts  a  gentle  stimulus  to  the  granulating  surface,  while 
protecting  it  from  contamination,  and  favors  the  filling  of  the 
cavity  and  the  inward  extension  of  new  skin  from  its  edges 
in  the  shortest  possible  time.  Later,  the  zinc-oxide  may  be- 
come too  stimulating,  shown  by  excessive  redness  of  the  granu- 
lations, when  it  should  be  replaced  by  a  20  per  cent,  mixture,  or 
simple  petroleum  ointment  until  the  part  has  skinned  over. 

Appearances  indicate  that  these  wounds,  so  treated,  heal 
with  remarkable  promptness  compared  with  wounds  otherwise 
produced,  rarely  requiring  skin  grafting  even  when  large  sur- 
faces are  denuded,  and  resulting  finally  in  soft  scars  of  ex- 
tremely small  area  compared  with  the  original  wound.  The 
general  tendency  is  the  formation  finally  of  a  simple  linear 
or  Y-shaped  scar,  of  slight  conspicuousness,  the  only  disad- 
vantage being  a  tendency  to  distortion  of  the  mouth  or  eye- 
lid when  the  wound  is  very  close  to  either  of  these  openings. 


84  operative  Details. 

In  the  latter  case  a  plastic  operation  may  be  resorted  to  later 
for  cosmetic  reasons. 

A  few  days  after  the  separation  of  the  slough  the  daily  criti- 
cal observation  of  the  wound  should  begin,  to  discover  any 
evidences  of  a  portion  of  the  growth  having  escaped  the  de- 
structive process.  The  characteristic  appearance  of  these 
disease  granulations  is  somewhat  difficult  of  description,  but 
it  may  be  said  that  they  are  larger,  rounder,  harder,  and  paler 
than  normal  granulations.  When  disease  is  left  in  the  edges 
of  the  wound  the  latter  are  almost  invariably  raised,  hard,  and 
usually  excavated  (though  at  times  rounded),  while  healthy 
edges  are  flattened,  continuous  with  the  surrounding  skin  or 
mucous  membrane,  and  show  the  bluish-white  color  of  new 
epidermis. 

In  the  presence  of  any  reasonable  doubt,  the  granulations 
should  be  attacked  at  once  by  a  series  of  minor  applications, 
which  are  quite  painless  at  some  distance  from  the  edges  of  the 
wound.  If  the  edges  themselves  are  doubtful,  a  second  major 
application  should  be  arranged  without  delay. 

THE    MIXOR   APPLICATIOX. 

The  minor  application  of  zinc-mercury  ionization  is  the 
designation  applied  to  all  applications  made  without  gen- 
eral anesthesia.  Any  form  of  local  anesthesia  may  be  used. 
They  may  be  made  at  the  office,  in  the  hospital  or  dispensar}-, 
or  at  the  patient's  residence. 

The  apparatus  required  is  a  current  source  and  applying 
mechanism  equal  at  least  to  the  ordinary  demands  of  the  con- 
stant current  in  gynecology,  having  a  good  graphite  controller 
of  approved  pattern  and  a  delicate  and  accurate  meter  regis- 
tering to  100  milliamperes  on  a  wide  scale.  The  Ionization 
Table,  the  Pope-^Massey  Wall  Cabinet,  and  the  improved  port- 
able apparatus  described  in  connection  with  the  technic  of  the 
major  application,  present  almost  equal  advantages  in  the 
minor  application,  the  chief  being  the  very  gradual  and  pain- 
less turn-on  possible  with  them. 

The  patient  lies  on  a  couch  with  the  part  to  be  treated 
exposed,  and  the  clothing  is  loosened  sufficiently  to  enable  a 
kaolin  pad  to  be  placed  on  the  abdomen  or  back.*    On  the  side 

*When  the  application  is  below  six  or  seven  milliamperes  the  kaolin 
pad  ma}'  be  placed  on  a  table  and  contact  made  by  the  patient  resting 
the  palms  of  the  hands  on  it  while  in  the  sitting  position. 


Minor  Application.  85 

of  the  pad  furthest  from  the  skin  the  thin  metal  plate  is  placed, 
of  appropriate  size,  and  connected  by  a  No.  26  wire  with  the 
negative  binding  post.  The  next  step,  if  the  site  of  the  pro- 
posed application  is  external,  denuded  of  skin  and  sensitive, 
is  the  placing  of  several  drops  of  a  strong  solution  of  cocaine 
at  the  site  of  the  puncture,  dropping  a  minute  bit  of  absorbent 
cotton  on  it  to  hold  the  solution  in  place  if  necessary.  This 
will  serve  to  benumb  sensation  very  materially  if  left  in  place 
while  the  active  electrode  is  being  prepared. 

The  minor  electrode  is  now  prepared  as  described  above, 
sharpened  and.  attached  to  the  piece  of  No.  32  copper  wire 
to  serve  as  conductor.  If  the  tissue  to  be  destroyed  is  beneath 
healthy  tissue,  and  a  sinus  exists,  it  is  insulated  as  described 
for  the  No.  2  electrode.  Should  the  surface  to  be  destroyed 
be  large,  several  such  electrodes  may  be  attached  to  the  leash 
of  wires  described,  but  more  than  one  electrode  is  only  employed 
in  situations  where  enough  current  can  be  used  to  give  each 
point  from  seven  to  ten  milliamperes,  at  least. 

The  electrode  or  electrodes  are  now  amalgamated,  attached 
to  the  positive  binding  post  of  the  battery,  and  gently  inserted 
into  the  growth,  care  being  observed  to  make  the  pressure 
of  insertion  vertical  to  avoid  breaking  the  instrument,  which 
is  now  quite  brittle  from  its  mercurial  coat. 

Perfect  stability  of  the  electrode  in  the  position  given  it 
is  best  secured  by  attaching  a  guy  of  adhesive  plaster  to  the 
wire  about  four  inches  from  the  electrode,  and  sticking  the 
ends  of  the  plaster  to  a  neighboring  skin  surface  in  such  a 
way  that  the  wire  itself  will  not  rest  on  the  skin,  since  its 
insulation  is  slight. 

The  electrode  or  electrodes  being  in  position  and  incapable 
of  being  disturbed  by  slight  movements  of  the  patient,  a  cur- 
rent is  slowly  and  gently  turned  on,  to  the  limit  of  the  patient's 
comfort.  This  will  vary  greatly  with  the  sensitiveness  of  the 
part,  and  should  also  bear  some  relation  to  the  quantity  of 
metal  capable  of  being  attacked  without  disappearance  of  the 
point  during  the  application,  thus  suddenly  interrupting  the 
current.  In  practice  the  limits  will  vary  from  2  or  3  to  80 
or  more  milliamperes.  Judged  from  the  point  of  view  of 
current  bulk  and  electrode  surface,  there  should  be  some  ad- 
justment of  the  size  of  the  points  to  the  current,  as  the  most 
effective  results  are  attained  when  the  points  are  nearly,  but 


86  Operative  Details. 

not  quite,  dissolved  during-  the  application.     With  small  cur- 
rents, very  fine  points  should  therefore  be  used. 

A  minor  application  for  malignant  disease  should  continue 
for  thirty  minutes,  invariably,  when  one  of  a  series  with  others 
to  follow,  counting  from  the  time  when  the  current  is  turned 
on.  In  tuberculous  deposits  fifteen  minute  applications  will 
be  sufficient.  The  current  should  be  turned  ofi  as  slowly  as 
it  was  turned  on,  as  any  sudden  variation  is  painful. 

The  part  is  dressed  with  the  half-strength  zinc-oxide  oint- 
ment on  gauze,  held  in  place  with  a  bandage  or  strips  of  zinc- 
oxide  plaster. 

The  minor  application  is  quite  effective  in  destroying  small 
growths  in  one  seance,  if  the  growths  are  not  situated  in  sensi- 
tive regions,  the  part  being  duly  inspected  after  separation  of 
the  slough  and  the  application  repeated  until  no  doubt  of  the 
destruction  of  the  growth  exists.  In  larger  growths  of  low 
malignancy  it  will  maintain  a  practical  asepsis,  and  if  re- 
peated daily  or  every  other  day,  may  ultimately  eradicate  the 
whole  of  the  diseased  area. 

Local  anesthesia  may  be  employed  with  this  method  in 
two  ways.  If  the  skin  must  be  punctured  for  the  insertion 
of  the  electrodes,  it  should  be  chilled  with  the  chloride  of 
ethyl  spray.  A  straight  Hagedorn  needle  makes  an  excellent 
bistoury  for  incising  the  skin.  When  the  electrode  has  been 
inserted,  a  small  drop  of  a  strong  solution  of  cocaine  in  water 
is  placed  on  the  opening  alongside  the  needle;  the  cocaine 
in  the  solution  will  be  carried  by  cataphoric  action  into  the 
wound  along  with  the  zinc  and  mercury  ions,  doing  much 
to  lessen  the  burning  sensation  that  develops  at  the  point  where 
the  ions  attack  the  skin.  When  the  puncture  is  into  granula- 
tions at  some  distance  from  the  skin,  neither  the  spray,  Hage- 
dorn needle,  nor  the  cocaine  will  be  necessary,  as  diseased 
granulations  are  quite  insensitive  and  easily  penetrated  by  the 
zinc  needles. 

A  more  extensive  local  anesthesia  may  be  produced  when 
considerable  skin  surface  is  to  be  destroyed  by  using  the 
<endermic  injection  method;  but  where  cocaine  is  to  be  thus 
employed,  it  should  be  in  the  weak  Schleich  solution,  which 
contains  morphia,  cocaine,  and  common  salt,  and  may  be 
freely  injected  into  the  skin  itself. 

The  No.  I,  or  non-insulated  electrode,  should  be  used  when 


Value  of  Zone  of  Reaction.  Sy 

a  sinus  is  to  be  created  through  healthy  tissues  for  subsequent 
treatment,  and  when  the  growth  is  a  surface  one  and  therefore 
does  not  require  that  the  instrument  be  insulated.  The  No. 
2,  or  insulated  electrode,  is  to  be  used  when  further  action 
on  the  walls  of  a  sinus  is  not  desired,  and  we  wish  to  con- 
fine the  action  to  the  underlying  tissue  alone. 

Value  of  Zone  of  Reaction  produced  by  the  Minor  Appli- 
cations.— Daily  diffusions  of  even  moderate  doses  of  the  ions 
of  mercury  and  zinc  are  often  practicable  in  somewhat  large 
growths  of  low  malignancy,  such  as  rodent  and  other  slowly 
growing  epitheliomas,  and  in  these  cases  both  the  operator 
and  patient  become  soon  convinced  of  the  reality  of  the  zone 
of  reaction  by  unmistakable  signs.  Under  these  applications, 
with  needles  at  each  application  passed  into  the  insensitive 
growth  itself,  a  sense  of  discomfort  and  burning  will  be  per- 
ceived by  the  patient  in  the  edges  of  the  growth  in  a  few  days 
that  can  only  be  explained  as  the  result  of  the  repeated  trans- 
mission outwards  of  the  ions  diffused  at  the  previous  appli- 
cations. The  physical  conditions  are  that  of  concentric  waves 
of  material  diffusion  from  the  electrode  or  electrodes,  each 
wave  halting  in  its  outward  progress  at  the  termination  of  the 
treatment,  but  being  started  up  again  by  the  next  one.  After 
ten  such  applications,  therefore,  the  eleventh  will  be  found 
to  start  up  ten  radiating  waves  of  diffusion  due  to  previous 
applications,  the  density  of  the  ions  diminishing  as  the  circle 
of  the  wave  widens,  with  consequent  weakening  of  effect 
towards  the  periphery. 

This  secondary  effect  of  such  frequently  repeated  applica- 
tions is  often  quite  notable  in  surface  growths,  such  as  those 
mentioned,  leading  finally  to  a  complete  reversal  of  the  in- 
sensitive conditions  prevailing  in  these  growths.  The  sur- 
rounding tissue  becomes  reddened  and  tender.  The  arousing 
of  the  physiologic  resistance  of  the  tissues  thus  indicated  can- 
not be  other  than  of  great  service  in  the  destruction  of  out- 
lying malignant  cells,  and  thus  contributing  towards  ultimate 
cure,  but  when  the  growth  is  too  large  or  too  virulent  for  this 
process  to  overwhelm  it,  the  reaction  only  increases  the  viru- 
lence of  its  growth.  In  such  cases  a  major  application  should 
be  used  without  delay. 


operative  Details. 


AFTER   OBSERVATION. 


One  of  the  most  imperative  duties  of  the  surgeon  is  that 
of  repeated  inspection  of  a  patient  after  an  operation  for  the 
destruction  of  a  cancer  to  ascertain  if  the  work  has  been 
complete  and  thorough.  With  the  possibiHties  of  minor 
ionization  at  hand  to  quickly  and  simply  destroy  local  foci 
overlooked  in  the  major  application  before  a  considerable  re- 
growth  has  occurred,  the  importance  of  after  inspection  is 
greatly  increased,  for  it  enables  us  to  snatch  many  a  victory 
from  otherwise  certain  defeat.  It  is  half  the  battle  in  this 
form,  of  war  against  cancer;  and  the  same  may,  in  fact,  be 
said  of  any  surgical  method. 

This  after  inspection  may  be  divided  practically  into  two 
periods:  that  between  the  separation  of  the  slough  and  the 
healing  of  the  wound;  and  that  between  the  healing  of  the 
wound  and  the  expiration  of  three  to  five  years  after  the 
healing. 

The  first  period  is  one  of  the  most  valuable  features  of  the 
ionization  method.  During  this  time  the  painless  wound  is 
open  for  the  most  thorough  obervation,  and  an  opportunity  is 
given  the  surgeon  to  apply  his  highest  skill  in  the  detection 
of  doubtful  nodules  and  prominences.  No  trained  application 
of  both  sight  and  touch  could  be  of  more  value  to  the  patient, 
and  both  of  these  senses  should  be  developed  by  the  worker  in 
this  field  to  their  highest  perfection. 

Practice  only  can  develop  this  nice  discrimination  between 
a  healthy  granulation  and  an  unhealthy  one,  but  the  important 
points  are  that  indurated,  rounded  granulations  should  he  re- 
garded :with  suspicion — a  suspicion  that  should  lead  to  their 
destruction  at  once  by  a  minor  application.  A  wound  that 
is  mainly  healthy  will  furnish  discharges  that  are  entirely 
free,  also,  from  the  characteristic  odor  of  cancer.  Any  return 
of  a  previously  present  odor  should,  therefore,  dictate  addi- 
tional treatment,  either  a  series  of  minor  applications  at  once, 
or  a  second  major  application  at  the  earliest  opportunity — 
usually  in  about  four  weeks  from  the  first.  Finally,  the  ap- 
proach of  a  normal  epidermization  in  the  edges  is  shown  by  a 
flattened,  soft  border  of  a  whitish-blue  color,  with  a  tendency 
to  a  puckering  contraction.  A  nodular,  raised,  dark-colored 
edge,  showing  no  tendency  of  the  wound  to  contract,  indicates 
the  imperative  necessity  for  further  treatment. 


Post-Operative  Treaimeni.  89 

Any  doubt  that  may  exist  as  to  the  true  nature  of  such 
granulations  should  be  decided  in  favor  of  intervention;  like 
Caesar's  wife,  normal,  post-operative  granulations  should  be 
absolutely  above  suspicion.  To  suspect  should  be  to 
condemn. 

Should  the  doubtful  granulations  be  at  some  distance  from 
the  sensitive  edges  of  the  skin  or  mucous  membrane,  towards 
the  middle  of  the  excavation,  they  are  readily  destroyed  by  a 
prompt  series,  or  at  times  a  single,  minor  application,  the 
insensitive  granulations  permitting  from  50  to  75  milliamperes 
to  be  used  without  pain.  If  the  edges  show  disease,  a  major 
application  is  imperative,  owing  to  the  pain  that  would  be 
produced  by  the  minor  method. 

The  second  period  of  after  observation,  extending  from  the 
healing  of  the  wound  until  the  expiration  of  three  to  five  years, 
is  fully  as  important  as  the  first  period,  and  I  fear  is  greatly 
neglected  by  surgeons  at  present,  who  would  find  evidences  of 
recurrence  much  earlier  than  common  if  they  were  systemati- 
cally looked  for.  To  obtain  full  cooperation  of  the  patient  he 
should  not  be  discharged  at  this  time  as  cured,  but  merely  as 
without  manifest  evidence  of  disease,  as  is  the  rule  at  the  Onco- 
logic Hospital,  being  obligated  in  writing  to  return  for  inspec- 
tion monthly  during  the  first  year  and  quarterly  during  the 
second  and  third  years  after  discharge. 

POST-OPERATIVE   RADIOTHERAPY   AND   PHOTOTHERAPY. 

Some  radiotherapeutists  lay  stress  on  the  value  of  post- 
operative radiation  to  insure  destruction  of  latent  cells  in  the 
region  of  the  wound.  This  would  seem  to  be  a  most  excellent 
procedure,  and  there  is  no  doubt  of  its  importance  in  some 
cases;  but  it  has  the  disadvantage  in  others  of  producing  a 
dermatitis,  while  in  all  cases  there  is  a  disturbed  nutrition  in 
the  wound  that  may  interfere  with  the  detection  of  slight  recur- 
rences near  the  surface  that  could  be  instantly  destroyed  by  a 
minor  application  if  discovered  promptly.  The  conditions  of 
each  case  must  dictate  the  proper  course  to  pursue,  the  author 
having  recourse  to  radiation  in  a  small  proportion  of  cases 
only  for  the  reason  given.  If  re-treatment  by  ionization  seems 
inadequate  in  a  given  case  of  recurrence  the  rays  should  be 
begun  at  once. 


90  Operative  Details. 

Phototherapy,  on  the  other  hand,  may  be  employed  to  assist 
the  heahng  process  in  any  large  denudations,  and  it  has  seemed 
to  the  author  to  be  valuable  to  quicken  the  healing,  and  to 
assist  in  the  determination  of  the  question  whether  the  granula- 
tions and  edges  of  the  wound  are  healthy  or  not. 


CHAPTER  VIIL 

CONCERNING   THE    CHOICE   OF    METHOD   IN    THE  TREATMENT   OF 
MALIGNANT  GROWTHS  IN  VARIOUS  SITUATIONS  AND  STAGES. 

There  is  to-day  no  more  important  question  in  medicine  than 
the  proper  method  of  convincing  the  pubHc,  and  possibly  also 
many  members  of  the  medical  profession,  of  the  supreme  im- 
portance of  early  and  vigorous  removal  of  all  accessible  cancer- 
ous growths  in  their  earliest  incipency.  This  means,  with 
the  exception  of  certain  skin  cancers,  and  possibly  certain  sar- 
comas, their  operative  removal.  The  exceptions  relate  entirely 
to  those  epitheliomas  which  even  in  their  incipiency  are  best 
treated  by  Roentgen  rays,  and  to  sarcomas  in  inaccessible  sit- 
uations. No  other  treatment  now  known,  including  all  the 
recent  fads,  need  be  considered  for  a  moment,  for  none  have 
verified  their  ability  to  do  more  than  cause  fatal  delay  in 
operable  cases. 

In  thus  stating  the  inevitable  need  of  operation  in  all  but 
the  excepted  cases,  and  immediate  operation  is  emphatically 
meant,  the  author  includes  of  course  the  methods  described  in 
the  preceding  pages,  for  the  ionic  destruction  of  cancer  can- 
not be  regarded  in  any  other  light  than  operative  removal 
of  the  disease,  even  though  it  may  not  be  accompanied  by  the 
loss  of  blood  usually  associated  with  operative  procedures. 

In  the  vast  majority  of  incipient  growths  the  question  is 
therefore  not  "  Shall  this  or  that  be  tried  before  operation  ?  " 
but  "  What  form  of  operation  is  best  suited  to  the  individual 
case  ?  " 

To  answer  such  a  question  to  the  best  advantage  requires 
usually  more  than  the  experience  of  any  one  operator,  for 
few  men  are  capable  of  comprehending  adequately  the  work 
of  another  greatly  differing  from  their  own.  This  difficulty 
is  one  that  is,  nevertheless,  readily  met  in  the  manner  anciently 
dictated  in  the  ethical  procedures  of  the  medical  profession. 
Consultation  is  the  key  to  the  best  results,  provided  only  that 
experience  and  judgment  be  both  secured  for  the  conference. 

91 


92  Choice  of  Method  in  Malignant  Growths. 

INDICATIONS     GOVERNING    THE     CHOICE     BETWEEN     IONIZATION 
AND   OTHER    METHODS. 

Taking  a  broad  view  of  the  subject,  some  remarks  may 
therefore  be  made  in  this  place  on  the  comparative  suitabiHty 
of  ionization  and  other  methods  in  individual  cases,  after 
briefly  enumerating  the  general  advantages  and  disadvantages 
of  several  methods. 

This  choice  of  operative  method,  it  should  be  understood, 
is  based  mainly  at  present  on  the  situation  and  stage  of  the 
growth  rather  than  its  type  or  variety,  though  considerations 
based  on  the  variety  dictate  important  modifications  of 
technic. 

Comparative  Advantages  of  Ionization. — As  compared  with 
excision  by  the  knife,  this  method  presents  the  following 
advantages :  The  cancer  cells  or  germs  are  killed  in  situ  at 
once  and  the  surrounding  absorbents  sealed,  preventing  the 
operative  re-infection  of  the  cut  edges  that  has  been  said  to 
accompany  the  former  method  when  the  incisions  are  perforce 
close  to  the  edges  of  the  growth;  it  permits  of  the  destruc- 
tion of  a  small  growth  in  certain  organs,  such  as  the  breast 
or  tongue,  'without  the  removal  of  the  whole  of  the  organ; 
in  spite  of  scepticism  natural  to  those  who  have  not  observed 
the  method,  it  may  be  depended  on  to  destroy  infected  glands 
in  the  axilla  (not  too  close  to  the  axillary  vessels)  more  thor- 
oughly than  incision ;  it  is  bloodless,  and  hence  may  be  em- 
ployed in  highly  vascular  growths  without  the  weakening  effect 
of  loss  of  blood;  and,  most  important  of  all,  it  permits  of  a 
strictly  localized,  bloodless  destruction  of  growths  within  ac- 
cessible cavities — such  as  the  nose,  mouth,  vagina,  and  rectum — 
by  the  use  of  insulated  electrodes,  without  disturbance  of  over- 
lying healthy  tissues  or  the  extensive  operations  necessary 
particularly  in  the  first  two  cavities  mentioned,  and  in  these 
cases,  without  the  danger  of  septic  pneumonia  from  insufflation 
of  blood,  as  often  happens  during  excision. 

No  comparison  is  possible  with  the  curette  in  the  treatment 
of  cancer,  as  this  instrument  should  be  looked  upon  as  capable 
only  of  aggravating  a  malignant  growth,  and  should  never  be 
used  in  such  cases.  A  minor  ionization  application  is  a  com- 
plete substitute  for  curettement,  accomplishing  all  that  curette- 
ment  may  do,  with  a  total  absence  of  its  disadvantages  and 
power  of  harm. 


Advantages  of  Ionization.  93 

As  compared  with  the  thermocautery  and  caustic  pastes, 
the  ionization  method  is  more  controllable  and  may  be  made 
to  reach  the  periphery  of  the  growth  at  once,  under  anesthesia, 
and  thus  painlessly  and  accurately  accomplish  in  a  few  minutes 
what  is  sought  to  be  done  blindly  by  caustics  during  weeks  of 
acute  suffering.  It  is  employed  as  easily  within  cavities  as 
externally.  The  periphery  (which  is  the  vital  portion  of  the 
growth)  is  sterilized  and  sealed  in  the  ionization  process. 
Finally,  the  slough  produced  is  sterilized  by  added  sterilizing 
ions  rather  than  temporarily  by  heat,  as  in  the  thermocautery, 
and  remains  sterile  and  odorless  the  greater  portion  of  the 
time  until  separation  occurs,  while  the  intensely  odorous 
sloughs  produced  by  the  thermocautery  are  well  known. 

The  amelioration,  and  at  times  actual  cure,  already  observed 
in  many  cases  of  malignant  disease  under  Roentgen  rays,  make 
a  comparison  of  this  method  with  zinc-mercury  ionization 
also  most  appropriate  at  this  time.  The  question  of  selection 
between  the  two  methods  is  one  largely  depending  on  the 
variety  of  the  growth,  though  its  situation  is  of  great  impor- 
tance. In  cases  that  present  but  little  difficulty  in  their  imme- 
diate eradication  by  ionization  or  excision,  and  in  which  de- 
lay would  increase  the  chances  of  internal  dissemination,  the 
selection  of  one  of  the  two  latter  methods  is  surely  the  part 
of  wisdom.  Should  ionization  fail  to  eliminate  all  of  the 
disease  in  the  first  application,  and  show  little  sign  of  success 
after  prompt  repetition  or  repetitions,  the  rays  should  be  begun 
at  once.  But  no  case  that  may  be  easily  brought  within  the 
powers  of  the  quicker  method,  particularly  no  case  presenting 
a  liability  to  metastasis  from  delay,  should  be  subjected  to  the 
uncertainties  that  yet  surround  the  radiation  method.  It  should 
be  remembered,  also,  that  certain  obscure  dangers  attend  re- 
peated radiation  that  are  not  found  in  connection  with  the 
ionic  method. 

Comparative  Disadvantages  of  Ionization. — As  compared 
with  the  knife,  one  disadvantage  of  this  method  is  the  cost 
of  the  apparatus  and  the  necessity  for  the  possession  of  a 
working  knowledge  of  medical  electrophysics  by  the  operator. 
This  need  but  to  be  mentioned  to  be  dismissed,  since  the 
cost  of  both  requisites  is  too  slight  to  be  put  into  the  scale 
with  life  itself.  A  real  disadvantage  in  a  highly  operable 
breast  case,  for  instance,  is  the  time  necessarily  spent  in  the 


94  Choice  of  Method. 

hospital  while  the  slough  separates,  as  compared  with  the  much 
shorter  time  required  in  hospital  after  excision.  Its  real  indi- 
cation in  breast  cases,  aside  from  the  eradication  of  small 
carcinomas  in  young  women  with  preservation  of  the  breast, 
is  in  the  treatment  of  breast  and  axillary  invasions  that  are 
past,  or  still  on,  the  border-line  of  knife  operability,  and  in  these 
cases  the  time  required  for  the  wound  to  close  is  a  distinct  ad- 
vantage, as  it  permits  of  an  observation  that  often  enables  us 
to  secure  success  in  the  face  of  impending  failure  by  showing 
the  need  of  additional  minor  applications. 

I\Iinor  ionic  applications  can  rarely  be  successfully  made 
to  deep-seated  growths  in  the  neck.  In  this  situation  a 
major  application  has  distinct  dangers,  both  by  interference 
with  the  pneumogastric  nerve,  thus  endangering  respiration 
and  circulation,  and  through  the  possibility  of  the  inclusion  of 
large  veins  in  the  destructive  process,  with  the  consequent  risk 
of  secondary  hemorrhage.  This  subject  will  be  further  dis- 
cussed in  the  chapter  on  applications  to  the  mouth. 

As  compared  with  caustics  and  the  thermocautery,  the 
ionic  method  has  no  disadvantage  whatever. 

Compared  with  x-rays,  the  ionization  method  has  the  dis- 
advantage of  requiring  anesthesia  at  times,  and  of  always  pro- 
ducing a  wound  at  the  site  of  the  growth ;  but  this  wound  is 
intelligently  made,  and  unlike  the  possible  wounds  produced 
by  x-rays,  is  sterile  and  heals  very  easily.  It  is  also  hoped 
that  radiotherapy  will  be  found  to  possess  the  advantage  of 
favorably  affecting  sarcomatous  growths  within  the  abdomen 
or  chest  which  are  beyond  the  reach  of  the  ionization  method. 
But  a  most  important  advantage  of  x-rays  over  ionization, 
in  skin  cancers  that  have  been  found  to  be  amenable  to  the 
rays,  is  the  fact  that  a  large  surface  may  be  simultaneously 
treated  by  the  rays,  while  the  growth  may  be  of  such  slight  depth 
as  to  be  capable  of  being  treated  by  ionization  in  a  minor 
form  only,  and  by  many  repetitions  in  small  areas.  Alternate 
employment  of  each  method  may  be  of  value  in  such  cases. 
A  disadvantage  of  ionization  in  the  treatment  of  epitheliomas 
near  the  eyelids  is  the  tendency  to  distortion  of  the  latter  in 
the  healing  process.  AVhen  such  growths  respond  to  the  rays 
this  sequel  does  not  usually  follow. 


Conclusions.  gc 

CONCLUSIONS  AS  TO  CHOICE  OF  METHODS. 

A  Statement  of  the  author's  conclusions  concerning  the 
selection  of  the  best  method  among  those  now  known  for  the 
treatment  of  a  definite  case  of  cancer  would  therefore  read  as 
follows : 

I.  The  knife,  being  preferred  as  the  simplest  remedy,  offers 
the  best  or  the  quickest  relief  in  the  following  situations :  All 
operable  growths  still  confined  to  the  interior  of  organs  that 
it  is  impossible  to  conserve  safely  and  that  are  capable  of  com- 
plete removal,  such,  for  instance,  as  the  eyeball;  the  uterus 
(when  confined  to  the  body,  but  not  the  cervical  variety)  ;  the 
ovary ;  the  testicle ;  all  strictly  internal  organs ;  and  the  highly 
malignant  sarcomas  of  the  extremities  where  high  amputation 
is  possible  (if  accompanied  by  ionic  sterilization  of  the 
infected  lymphatic  glands  above  the  seat  of  amputation).  A 
mammary  carcinoma  without  advanced  infection  of  the  axil- 
lary glands— in  other  words,  a  "highly  operable"  case,  in 
which  so  much  of  the  gland  is  affected  as  to  preclude  the  possi- 
bility of  saving  the  greater  portion  of  the  breast— should  be 
removed  by  the  knife  together  with  the  tissues  of  the  axilla, 
provided  a  wide-sweeping  operation  be  done,  for  this  procedure 
should  be  as  free  from  chances  of  recurrence  as  a  thorough 
ionic  destruction,  and  convalescence  is  shorter. 

2.  Ionization  should  be  employed  in  most  operable  and 
some  inoperable  external  growths  where  experience  has  shown 
that  the  prevention  of  recurrence  is  difficult  after  knife  opera- 
tions, or  where,  as  in  the  face,  tissue  may  be  successfully  saved 
and  a  better  cosmetic  result  secured  by  this  method.  In  all 
small  incipient  growths  of  the  skin  it  is  both  more  easily 
applied,  more  successful,  and  less  abhorrent  to  the  patient;  and 
as  it  is  more  likely  to  be  accepted  by  patients  in  earlier  stages 
of  the  growth  than  the  knife,  an  additional  chance  of  cure 
of  great  importance  is  presented  by  it.  In  mammary  car- 
cinoma an  early  or  doubtful  cancerous  nodule  in  a  young 
woman  may  be  eradicated  by  ionization  without  loss  of  the 
breast,  and  the  same  may  be  said  of  a  cystoma  of  the  breast. 
It  is  also  believed  by  the  author  to  promise  the  better  result 
as  compared  with  the  knife  in  advanced,  semi-adherent  car- 
cinomas of  the  breast  with  well-defined  masses  in  the  axilla 
(if  the  higher  axillary  glands  are  not  affected).  But,  far 
and    above    any    other    method,    ionization   is    most    suitably 


96  Choice  of  Method. 

applied  to  malignant  growths  in  the  accessible  cavities  of  the 
body;  the  nasal  cavities,  the  mouth,  vagina,  and  rectum. 

Finally,  in  so-called  inoperable  cases  in  many  situations  it 
presents  a  valuable  means  of  palliation,  though  its  use  for 
this  purpose  is  likely  to  prejudice  its  employment  in  the  true 
sphere  of  its  greatest  usefulness:  the  destruction  of  incipient 
growths. 

3.  Radiotherapy  should  be  used  in  extensive  skin  cancers 
of  low  virulence  and  slight  depth,  where  ionization  would 
be  tedious  or  impracticable :  it  should  be  tried  in  epitheliomas 
near  the  eyelids,  where  ionization  or  other  methods  might 
cause  distortion  of  the  lids;  it  often  succeeds  where  all  other 
methods  have  failed  in  surface  growths;  and  it  has  caused 
the  disappearance  of  some  internal  sarcomas. 

4.  A  combination,  or  serial  employment,  of  two  or  more  of 
the  methods  mentioned,  as  conditions  arise,  is  at  times  the 
wisest  course  to  pursue  in  the  treatment  of  an  intractable  case, 
leading  possibly  to  an  eradication  of  a  still  local  cancerous 
growth  that  would  not  have  yielded  to  any  one  method  alone. 

CHOICE   OF   MAJOR  OR   MINOR   IONIC   APPLICATIONS   IN    A   GIVEN 

CASE. 

The  question  whether  a  case  for  which  the  ionic  method 
is  selected  can  be  successfully  treated  by  the  minor  method, 
or  demands  a  major  operation,  is  one  at  times  difficult  of  deter- 
mination, though  the  general  principles  of  choice  are  clear. 
No  highly  malignant  carcinoma  or  sarcoma  in  any  situation, 
should  he  subjected  to  the  risk  involved  in  the  delay,  and 
possible  aggravation  essential  to  the  minor  method  unless  it; 
is  so  small  as  to  be  eradicable  in  from  two  to  three  applica-* 
tions — preferably  in  one  application.  This  at  once  places  the 
majority  of  carcinomas  and  sarcomas,  in  the  late  stages  in 
which  we  at  present  first  see  them,  in  the  list  of  those  re- 
quiring the  major  application. 

The  minor  method  may,  nevertheless,  be  effective  in  very 
extensive  growths  of  low  malignancy  where  the  major  appli- 
cation is  inadvisable  because  of  the  feebleness  of  the  patient, 
or  because  a  thorough  application  by  the  major  method  would 
be  too  extensive  a  wound  for  subsequent  cosmetic  reasons ; 
but  such  cases  must  be  of  the  kind  that  have  existed  for  years 
without  the  appearance  of  metastasis  or  of  extension  to  over- 


Choice  of  Major  or  Minor  Method.  97 

lying  skin  or  mucous  membrane.  Of  the  more  virulent  varie- 
ties, those  of  the  small  size  mentioned  above,  when  in  insensi- 
tive situations,  may  be  effectually  destroyed  by  minor  applica- 
tions, as  well  as  those  recurrent  nodules  found  just  beneath  the 
skin  after  amputation  of  the  breast  for  carcinoma.  These 
nodules  are  no  larger  than  a  pea,  if  diligently  searched  for 
during  the  first  weeks  after  the  operation,  and  represent  either 
unnoted  pre-operation  tissue  colonies,  infected  lymphatic 
valves,  or  direct  re-implantations  of  cells  during  the  cutting 
operation.  Carcinoma  of  the  cervix  uteri  in  its  earlier  stages 
is  also  suitable  for  what  is,  in  this  situation,  a  minor  applica- 
tion, though  the  insensitive  nature  of  this  area  permits  the 
stretching  of  the  term  "  minor  "  to  cover  applications  without 
anesthesia  of  one  and  two  hundred  milliamperes  for  thirty 
minutes.  Rodent  cancer  of  the  face  is  often  best  treated  by 
the  minor  method,  though  when  the  growth  is  extensive  many 
applications  extending  over  a  long  time  may  be  required,  the 
particular  advantage  of  the  minor  method  in  this  instance 
being  the  lessened  scar  that  finally  results.  The  minor  method 
is,  of  course,  applicable  to  all  small  growths  that  are  properly 
classed  as  but  moderately  malignant. 

Distinctly  virulent  grozvths,  even  of  small  size,  require  the 
major  method  when  situated  in  sensitive  areas  such  as  the  lip, 
breast,  anus,  etc.,  though  complete  sterilization  may  be  efTected 
in  a  few  minutes,  as  the  pain  produced  by  the  minor  applica- 
tion in  these  situations  precludes  its  use. 

Finally,  we  must  be  prepared  to  promptly  apply  minor  appli- 
cations to  suspicious  granulations  appearing  before  the  healing 
of  large  wounds  after  the  separation  of  the  slough  of  major 
applications,  as  our  best  results  may  be  thus  snatched  from 
impending  defeat.  The  open  wound  of  the  ionic  method 
becomes  from  this  point  of  view  one  of  its  chief  advantages. 


CHAPTER  IX. 

APPLICATIONS   TO    THE    FACE. 

The  author's  experience  in  the  actual  employment  of  electro- 
chemical methods  in  malignant  growths  indicates  the  need  of 
considerable  variation  in  the  technic,  in  accordance  with  the 
local  situation  of  the  neoplasm,  and  to  a  less  extent  with  its 
variety.  A  special  treatment  of  the  subject  from  this  point 
of  view  is  therefore  necessary,  and  this  special  consideration 
is  best  emphasized  by  a  full  report  of  some  cases  illustrating 
each  region,  so  far  as  possible. 

Basis  of  Selection  of  Cases  for  Illustration. — In  selecting 
these  cases,  only  those  that  were  finally  cured  will  be  reported 
in  detail  from  the  first  series  of  cases  treated,  or  those  extend- 
ing from  1893  to  1905,  as  this  series  of  seventy-nine  cases 
was  largely  experimental,  and  many  of  them  would  now  be 
rejected  as  unsuitable  for  the  demonstration  of  the  value  of  a 
novel  method ;  the  total  number  treated  in  each  portion  of  the 
body  will  nevertheless  be  given.  Of  the  second  series,  embrac- 
ing those  placed  under  treatment  since  January  i,  1905,  all 
will  be  reported  in  the  order  of  their  admission,  special  space 
being  given  to  those  having  a  teaching  value. 

The  classification  into  "  operable "  and  "  inoperable "  is 
based  entirely  on  the  apparent  operability  of  a  case  by  the 
knife  and  has  no  reference  to  its  operability  by  the  ionization 
method.  Such  a  classification  is  modified  by  the  personal 
equation  of  the  surgeon  making  it,  of  course,  yet  it  is  of 
much  service  in  differentiating  the  curative  or  merely  pallia- 
tive value  of  a  new  method,  to  which  physicians  are  apt  to 
turn  for  the  relief  of  desperate  cases  only,  after  other  methods 
have  been  tried  and  have  failed. 

Epitheliomas  of  the  face  are  peculiarly  well  adapted  to  com- 
plete destructive  sterilization  by  zinc-mercury  ionization,  and 
when  the  growth  is  small  it  may  be  destroyed  with  such 
delicate  limitations  of  the  destructive  process  to  the  actually 
diseased   cells,   particularly   when   the   minor   method   is   em- 


Applications  to  the  Face.  99 

ployed,  that  the  resulting  scar  is  less  conspicuous  than  that 
produced  by  any  other  method  except  the  x-ray.  This  adapts 
it  to  the  effective  destruction  of  small  growths  near  the  eyes,  or 
in  situations  where  unnecessary  loss  of  substance  will  lead  to 
conspicuous  deformity.  By  repeated  employment  of  from  3  to 
5  milliamperes  for  the  regular  half-hour  durations  the 
malignant  tissue  alone  is  destroyed,  resulting  in  a  minimal 
scar,  and  only  such  loss  of  normal  tissue  as  had  been  actually 
destroyed  by  the  malignant  process.  In  some  cases  a  pucker 
at  the  site  of  the  growth  will  follow  healing  if  much  tissue 
had  been  destroyed  by  the  morbid  process. 

The  same  reasons  that  make  the  minor  applications  pecu- 
liarly valuable  in  small  epitheliomas  render  them  of  great 
service  also  in  early  recurrences,  particularly  of  rodent  cancer 
(epithelioma  of  the  short  hair  follicles),  which,  if  primarily 
of  small  size,  may  be  destroyed  by  one  or  more  minor  applica- 
tions in  the  beginning,  but  in  any  case  will  require  careful 
watching  for  some  months  after  healing  in  order  that  the 
minute  pearls  of  recurrence  on  the  surface  may  receive  addi- 
tional applications  from  time  to  time  until  a  final  cure  has  been 
attained.  When  the  rodent  cancer  is  extensive  a  major  appli- 
cation of  200  to  300  milliamperes  should  be  made  at  once,  with 
twenty  or  more  fine  points  attached  to  a  leash  of  No.  32  wire; 
but  in  all  cases  the  minor  method  will  be  likely  to  be  needed  to 
complete  the  cure. 

When  the  growth  is  close  to  the  eye  or  ear  the  importance 
of  turning  the  current  on  and  off  gradually  is  greater  than 
elsewhere,  especially  in  the  minor  method  without  general 
anesthesia,  as  harmless  but  unpleasant  flashes  or  dizziness  are 
sure  to  accompany  a  rapid  increase  or  decrease  even  with  a 
few  milliamperes,  and  a  sudden  interruption  is  quite  discon- 
certing. The  minor  method  is  nevertheless  very  effective  in 
cases  of  slight  virulence  at  the  actual  margin  of  the  eyelids  or 
in  the  immediate  vicinity  of  the  auditory  apparatus.  The 
technic  of  applications  within  the  orbit  will  be  referred  to 
later. 

If  the  epithelioma  be  large,  a  major  application  is  neces- 
sary, unless  the  virulence  of  the  growth  is  very  slight.  Since 
only  from  200  to  350  milliamperes  are  advisable  by  the  mono- 
polar method,  large  epitheliomas  of  the  face  should  be  de- 
stroyed by  the  bipolar  method,  as  from  500  to  800  milliamperes 


,c.     ^^ 


':5    ^ 


100  Applications  to  the  Face. 

may  be  thus  used,  with  great  saving  of  time  under  the  anes- 
thetic and  a  greater  certainty  of  eradicating  the  growth. 

EpitheHomas  of  the  Hps  demand  a  major  application  under 
general  anesthesia,  either  bipolar  or  monopolar,  if  at  all  exten- 
sive, owing  to  the  exaggerated  tenderness  of  this  region  and 
the  usual  virulence  of  labial  cancer. 

Carcinomas  and  sarcomas  of  the  regions  under  consideration 
are  often  capable  of  effective  treatment  by  ionization.  If 
deep-seated  the  facial  artery  should  be  ligated  before  the  appli- 
cation to  prevent  secondary  hemorrhage.  In  these  cases 
search  should  be  made  for  enlarged  glands  in  the  neck,  which, 
if  found  to  be  still  movable,  should  be  raised  from  their  bed 
by  passing  a  threaded  curved  needle  beneath  them,  using  the 
thread  as  a  tractive  agent  to  draw  them  away  from  the  vessels 
and  nerves,  passing  the  active  needles  beneath  them  and  apply- 
ing a  strong  bipolar  current  with  the  negative  held  against  the 
skin  over  the  gland  and  within  the  loop  of  thread.  The  ionic 
method  should  not  be  employed  if  the  infected  glands  be  im- 
movable or  deep-seated. 

The  active  electrodes  in  face  cases  should  be  short,  to  avoid 
interference  with  the  anesthetizer,  light  in  weight  so  that  they 
will  remain  in  position,  and  with  sharp  points  for  ready  inser- 
tion. They  should  be  attached  in  sets  of  two  or  four  to  No.  32 
wire  and  so  anchored  by  plaster  guys  to  the  near-by  skin  that 
they  will  not  be  dislodged  by  accidental  movements  of  the 
patient. 

The  dispersing  electrode,  when  bipolar,  should  be  about 
half  as  large  as  the  surface  of  the  growth,  and  supplied  with 
absorbent  gauze  to  retain  the  anion-absorbing  acid.  In  mono- 
polar operations  the  dispersing  pad  should  be  beneath  the  back. 

FIRST  SERIES. 

No.  45,  Private  Case  Book.  Epithelioma  of  Side  and 
Bridge  of  Nose,  with  Metastasis  to  Neck. — Mrs.  L.,  aged  84, 
was  referred  by  Dr.  D.  F.  Woods,  of  Philadelphia,  September 
9,  1901.  There  is  an  open  cancerous  ulceration  on  left  side 
of  the  nose,  eroding  the  bones  of  same  and  a  portion  of  the 
right  side,  and  opening  both  nostrils.  The  erosion  extends  to 
the  inner  commissure  of  the  left  eye  and  threatens  to  invade  the 
orbit.  There  is  a  very  large  pyramidal  swelling  on  the  left 
side  of  the  neck,  below  the  jaw,  which  is  evidently  due  to  the 


Applications  to  the  Face.  lOl 

coalescence  of  a  number  of  infected  glands.  The  latter  growth 
is  immovably  fixed  in  the  deep  structures  of  the  neck,  is  the 
source  of  more  pain  to  the  aged  and  enfeebled  patient  than 
the  primary  growth,  and  is  absolutely  inoperable.  The  rela- 
tives asked  simply  that  the  nasal  growth  be  arrested,  if  pos- 
sible, before  it  attacked  the  eye. 

A  major  monopolar  application  was  therefore  made  to  the 
primary  growth,  200  to  300  millamperes  being  applied  with 
6  to  12  fine  points  for  one  hour  and  twenty  minutes,  under 
general  anesthesia,  assisted  by  Drs.  Richard  Woods,  Her- 
mance,  and  Okie.  The  ether  was  badly  borne,  and  the  patient 
was  quite  weak  for  some  weeks. 

October  12.  All  sloughs,  with  some  spicules  of  bone,  have 
separated,  leaving  a  wound  with  healthy  edges.  Patient  no 
longer  suffers  from  pain  in  site  of  original  disease,  but  has 
great  pain  in  the  metastatic  growth  in  the  neck. 

The  patient  died  during  the  following  winter  from  exten- 
sion of  the  secondary  growth,  but  there  was  no  sign  of  recur- 
rence in  the  nasal  region,  and  the  eye  was  saved. 

No.  50,  Private  Case  Book.  Carcinoma  of  Bridge  of 
Nose. — Mrs.  S.,  aged  68,  referred  by  Dr.  Wm.  B.  Ulrich,  of 
Chester,  Pa.,  December  23,  1901.  Six  weeks  before  this  date  a 
small  pimple  had  appeared  on  the  right  side  of  the  bridge  of 
the  nose.  It  was  painless,  but  its  rapid  growth  induced  Dr. 
Ulrich  to  send  the  patient  to  Prof.  Duhring,  of  the  University 
of  Pennsylvania,  for  diagnosis.  Dr.  Duhring  pronounced  the 
growth  an  epithelioma,  and  advised  its  removal  by  electricity. 

A  photograph  of  the  growth  was  taken  at  this  time  (Fig. 
21),  it  being  about  the  size  of  a  pea,  resting  on  a  raised  and 
indurated  base  the  size  of  a  penny.  The  minor  method  was 
begun,  with  very  fine  zinc-mercury  needles  and  tri-weekly 
applications  of  as  much  current  as  the  patient  could  easily 
stand,  with  cocaine  solution  at  point  of  insertion — about  three 
to  ten  milliamperes.  It  was  soon  seen,  however,  that  these 
mild  applications  were  worse  than  useless,  seeming,  in  fact, 
to  stimulate  the  growth,  which  rapidly  enlarged.  We  had  evi- 
dently to  deal  with  a  rapidly  growing  cancer  of  a  virulent 
type. 

A  major  monopolar  application  was  therefore  made  Jan- 
uary 16,  1902,  200  ma.  being  used  with  fine  points  for  40  min- 
utes under  ether,  with  the  assistance  of  Drs.  Ulrich  and  Her- 


I02 


Applications  to  the  Face. 


mance.  This  resulted  in  complete  destruction  of  the  growth, 
which  was  found  to  involve  the  nasal  bones,  the  upper  surface 
of  which  separated  spontaneously  three  months  later,  leaving 
a  healthy  base  which  healed  over  nicely.  A  small  opening 
into  the  left  nostril   remained,   with   healthy  edges,   but  the 


Fig.  21. — Case  No.  50  before  treatment. 


patient  was  contented  with  the  cosmetic  result  without  the 
intervention  of  a  plastic  operation,  which  was  advised. 

There  was  no  recurrence  up  to  the  time  of  her  death  from 
heart  disease  five  years  later,  in  her  74th  year. 

No.  51,  Private  Case  Book.  Epithelioma  of  the  Chin. — 
John  McW.,  electrician,  aged  56,  was  referred  by  Dr.  Chas. 
E.  Taylor,  of  Irwin,  Pa.,  March  3,  1902.  Three  years  ago 
what  appeared  to  be  a  pimple  on  the  chin  was  cut  in  shaving, 
after  which  it  grew  rapidly.  There  is  a  raised,  indurated 
patch  on  the  corner  of  the  chin  that  is  plentifully  supplied 
with  tortuous  vessels,  3  cm.  in  breadth,  and  ulcerated  in  the 
center.  It  is  painless.  As  the  patient  was  compelled  to  return 
to  Pittsburgh  at  onCe,  the  growth  was  destroyed  by  a  minor 
application  in  the  office,  sensation  being  lessened  by  the  in- 
jection of  a  weak  cocaine  solution  into  the  part.     A  current  of 


Applications  to  the  Face. 


103 


forty  milliamperes  was  used  for  one  hour  and  twenty-six 
minutes. 

June  14,  1908.  Patient  returns  with  a  small  recurrence  in 
edge  of  scar.     Twenty  ma.  for  one  hour  and  ten  minutes. 

July  15,  1908.  Patient  reports  by  letter  that  the  wound 
has  healed,  and  that  he  does  not  think  any  disease  remains. 

No.  64,  Private  Case  Book.  Epithelioma  of  Cheeks. — 
Miss  S.  B.  I.,  aged  44,  was  referred  by  Dr.  Leonard  Judd,  of 
Philadelphia,  August  19,  1903.  For  two  years  she  has  had  a 
slowly  growing  skin  tumor  on  the  right  cheek  beneath  the  eye. 
One  year  ago  she  was  under  the  care  of  a  prominent  derma- 
tologist of  this  city,  who  failed  to  arrest  its  growth.  In  June 
she  saw  Prof.  Duhring,  who  made  a  diagnosis  of  epithelioma. 
There  is  a  raised,  proliferating  growth  the  size  of  a  penny, 
with  indurated  base  and  covered  with  a  crust. 

August  19,  1903.  Minor  application,  20  ma.  for  30  min- 
utes. 

August  I,  1908.     No  recurrence  to  date. 


SUMMARY  OF   FIRST  SERIES   OF 

FACE  AND 

SCALP  CASES. 

Operable    Cases. 

Without    manifest    evidence 

of   disease   at   latest 

report 

4 

Ameliorated 
I 

Failed 
0 

Died  under 
treatment 

0 

Inoperable  Cases. 

Without   manifest   evidence 
of   disease   at   latest 
report 
0 

Ameliorated 
4 

Failed 
0 

Died  under 
treatment 

0 

SECOND   SERIES. 

No.  28.  Oncologic  Hospital.  Rodent  Epithelioma  of 
Upper  Lip. — Mrs.  H.  B.  B.,  aged  73.  Admitted  to  dispen- 
sary January  23,  1905.  She  had  had  the  erosion  on  the  upper 
lip,  shown  in  Fig.  22,  four  years.  She  received  a  minor  zinc- 
mercury  application  of  i  to  3  milliamperes  for  thirty  minutes, 
once  a  week,  for  three  months,  being  in  feeble  health.  The 
second  photograph,  Fig.  23,  was  taken  October  7,  1905. 

December  3,  1907.  Patient  reports  through  daughter-in- 
law  that  there  is  no  recurrence. 

No.    93.     Oncologic    Hospital.     Rodent   Epithelioma    of 


104 


Applications  to  the  Face. 


Face. — F.  W.,  aged  55,  was  admitted  to  dispensary  March  30, 
1905,  with  an  ulceration  on  one  side  of  the  nose  near  eye, 
shown  in  Fig.  24.  It  had  appeared  two  years  before,  had  the 
characteristic  raised  edges  of  a  rodent  cancer,  and  was  1^4  cm. 
in  diameter.  X-ray  treatment  had  been  applied  by  an  expert 
for  nine  months  with  temporary  benefit  and  recent  increase  in 


Fig.  22. — Case  28  before  treatment,  January  23,  1905. 


m 

WB 

~,y  -'i.  "-ai. 

^HM^^H^^H 

HE"' 

-"H. 

.^^ 

1 

1      1 

H 

m 

.    ^m 

J 

_J 

Fig.  23. — Case  28  nine  months  after  treatment.     No  recurrence  three 

years  later. 

size.  A  minor  application  of  4  milliamperes  was  made  for  a 
half-hour  with  two  needles,  several  drops  of  cocaine  solution 
having  been  placed  on  the  wound.  Two  weeks  later  the  scab 
came  off,  showing  no  sign  of  disease. 

November  20,  1905.  Patient  reports  with  one  small  pearl 
of  recurrence.  Minor  application  by  Dr.  McClary  of  2  milli- 
amperes for  ten  minutes. 

December  7,  1907.     Reports  at  dispensary  without  manifest 


Applications  to  the  Face. 


105 


Fig.  24. — Case  93  before  treatment,  March  30,  1905. 


Fig.  25. — Case  93.    Appearance  four  and  one-half  years  after  treatment. 


io6  Applications  to  the  Face. 

evidence  of  disease.  The  photograph,  Fig.  25,  was  taken  at 
this  time. 

October  27,  1909.  Patient  seen  at  his  home.  Scar  remains 
exactly  as  shown  in  Fig.  25. 

No.  133.  Oncologic  Hospital.  Epithelioma  of  Cheek,  of 
Small  Size.—yirs.  J.  A.,  aged  60,  admitted  to  the  dispensary 
May  9,  1905.  A  scaly  elevation,  i  by  one-half  cm.,  has  been 
present  seven  or  eight  years.  X-rays  applied  in  near-by  city 
had  no  effect.  Minor  application  of  10  ma.  for  half-hour,  two 
needles.  Returned  to  dispensary  by  request  February  13, 
1906,  showing  no  manifest  evidence  of  disease. 

No.  140.  Oncologic  Hospital.  Rodent  Epithelioma  of 
Forehead. — Mrs.  M.  C,  aged  46,  admitted  to  dispensary  May 
23,  1905,  with  several  isolated  nodules  of  the  disease  covering 
a  surface  about  4  by  5  cm.,  recurrent  after  x-ray  treatment. 
The  disease  had  existed  four  years,  and  she  had  had  the  x-rays 
for  9  months.  Minor  applications  of  4  to  5  ma.,  with  4 
needles,  have  been  given  on  ten  different  occasions,  as  the 
patient  returned  for  treatment,  with  great  improvement.  No 
sign  of  disease  now  for  a  year. 

No.  163.  Oncologic  Hospital.  Rodent  Epithelioma  of 
Nose. — J.  C,  aged  69,  admitted  to  house  June  26,  1905.  The 
tip  and  both  sides  of  the  nose  were  the  seat  of  a  deep  erosion, 
leaving  but  about  two-thirds  of  the  external  nose  unaffected. 
The  disease  had  been  present  for  sixteen  years,  during  ten  of 
which  extensive  progress  had  been  made.  Caustic  paste  had 
been  applied  one  year  before,  and  the  x-rays  at  a  city  hos- 
pital. 

Minor  applications  proving  too  painful,  he  was  placed  under 
ether  July  12,  and  a  major  monopolar  application  made  of  350 
to  400  milliamperes  for  50  minutes,  about  12  very  small  needles 
being  used.  Recovery  was  uneventful,  and  he  was  discharged 
August  I  St.  There  was  no  recurrence,  the  patient  dying  a 
year  later  of  pneumonia. 

No.  164.  Oncologic  Hospital.  Lupus  of  Face. — J.  O., 
aged  49,  admitted  to  dispensary  June  26,  1905,  with  a  lupoid 
patch  on  left  cheek.  Minor  applications  of  3  to  5  ma.  were 
made  on  several  occasions,  when  the  patient  abandoned  the 
treatment.  In  December,  1907,  reported  at  dispensary  by  re- 
quest in  excellent  condition,  having  received  x-ray  treatment 
at  a  hospital  near  his  residence. 


Applications  to  the  Face.  107 

No.  187.  Oncologic  Hospital.  Epithelioma  of  Skin  of 
Nose. — Mrs.  E.  P.,  aged  53,  admitted  to  the  house  from  Gibbs- 
boro,  N.  J.,  July  17,  1905,  with  an  ulceration  on  side  of  nose 
near  canthus  of  left  eye,  of  some  years'  duration.  It  was  1^2 
cm.  in  diameter,  and  had  the  characteristic  raised  edges  of 
rodent  cancer.  Monopolar  application  under  chloroform,  25 
ma.  for  fifteen  minutes.  Discharged  to  dispensary  for  ob- 
servation August  nth. 

November  26,  1906.  Reported  at  dispensary  with  a  single 
pearl  of  recurrence.     Minor  application. 

No.  219.  Oncologic  Hospital.  Lupus  of  Nose. — Mrs. 
E.  H.  S.,  aged  ^2.  was  admitted  to  dispensary  August  28,  1905, 
with  a  chronic  ulcer  on  the  tip  of  the  nose  clinically  resem- 
bling lupus.  It  had  resisted  remedial  efforts  for  five  years. 
Minor  application  of  20  ma.  was  made  for  half-hour.  Five 
ma.  were  applied  similarly  November  7th,  and  six  ma.  No- 
vember 28  of  same  year.  Reported  at  hospital  without  re- 
currence in  November,  1906. 

No.  234.  Oncologic  Hospital.  Epitheliomatons  Patches 
on  Face  and  Ears. — C.  H.  S.,  aged  63,  applied  to  dispensary 
June  26,  1905,  with  multiple  senile  epitheliomata  on  left  cheek 
(Fig.  26),  and  on  the  helices  of  each  ear,  of  two  years'  dura- 
tion. Under  cocaine  a  minor  application  of  as  much  as  40  ma. 
for  30  minutes  was  made  to  the  principal  growth,  and  on  a  sub- 
sequent occasion  each  of  the  other  growths  received  applica- 
tions of  8  ma.  for  15  minutes  and  3  ma.  for  10  minutes.  Fig. 
27  shows  the  condition  September  14,  1905. 

January  10,  1908.  In  response  to  letter  patient  states  that 
there  has  been  a  recurrence  of  the  growth  on  the  cheek,  but 
that  he  is  confined  to  bed  with  rheumatism  and  unable  to  re- 
turn for  further  treatment. 

No.  243.  Oncologic  Hospital.  Recurrent  Carcinoma  of 
Scalp. — Mrs.  S.  D.,  aged  50,  was  referred  by  Dr.  Eckman, 
of  Philadelphia,  October  3,  1905,  with  a  proliferating  growth 
on  the  occiput  about  4  cm.  in  diameter.  For  20  years  she  had 
had  a  wen  on  the  site  of  the  growth  which  she  says  gave  her 
"  no  trouble  "  until  one  year  ago,  when  it  became  painful  and 
was  opened  by  a  physician.  It  failed  to  heal,  and  was  later 
curetted  (in  March,  1905).  In  April  it  was  removed  by  ex- 
cision.    She  suft'ered  from  severe  headaches. 

October  4,   1905.     Major  monopolar  operation,  250  to  300 


io8 


Applications  to  the  Face. 


milliamperes  for  65  minutes.     Microscopic  examination:  Car- 
cinoma. 

October  21,  1905.  Patient  discharged  with  some  evidence 
of  disease  in  wound  and  no  rehef  of  headaches.  During  No- 
vember and  December  the  patient  received  eight  minor  appli- 


^^^H 

Kpx^^^-7j-^s — " 

1^1 

IMP 

^^^a 

'^m 

1 

-■iMii 

% 

^^'  ' 

Wf  ■ 

\^ 

^           i 

i 

Fig.  26. — Case  234  before  treatment,  June  26,  1905. 


cations  varying  from  25  to  45  milHamperes,  and  ceased  attend- 
ance owing  to  weakness. 

The  patient  died  several  months  later  of  extension  to  the 
brain. 

Xo.  256.  OxcoLOGic  Hospital.  Small  Epithelioma  of 
Bridge  of  Nose. — A.  McL.,  aged  70,  admitted  to  dispensary 
October  30,  1905,  with  a  growth  clinically  resembling  epithe- 
lioma and  about  the  size  of  a  pea,  on  the  bridge  of  nose. 
]\Iinor  application,  6  to  9  ma.  for  18  minutes. 

February  26,  1906.  Reports  at  dispensary  with  no  evidence 
of  disease. 

No.  85,  Private  Case  Book.  Multiple  Senile  Epitheliomata. 
J.  M.  R.,  aged  yy,  of  Camden,  Dela.,  was  referred  by  Dr. 
Leonardo  Judd,  of  Philadelphia,  December  5,  1905.  His 
father  had  callosities  on  hands,  and  a  maternal  uncle  died  of 
cancer.  For  8  or  10  years  he  has  had  an  epithelial  growth 
with  crusts  just  above  the  inner  canthus  of  the  left  eye.  He 
had  a  similar  growth  excised  five  vears  ago. 


Applications  to  the  Face. 


109 


The  growth  is  an  epithehal  ulceration  surmounted  by  a 
crust,  about  ij^  by  2  cm.  in  size.  Minor  appHcation,  7  ma. 
for  20  minutes,  4  points. 

January  29,  1907.  There  is  a  small  nodule  in  scar  of  pre- 
vious application.  There  is  also  a  new  growth  on  the  side 
of  cheek  about  the  same  size  as  the  one  over  the  eye  when  first 
treated.  Both  spots  received  a  simultaneous  minor  application 
of  10  ma.  for  one  hour. 

September  13,  1907.  Perfect  scar  at  site  of  growth  on 
cheek.  In  the  scar  over  left  eye  i  milliampere  is  applied  for 
20  minutes. 


Fig.  2/. — Case  234  after  treatment,  September  14,  1905. 

July  18,  1908.  Returns  with  both  scars  in  perfect  condi- 
tion, but  with  a  new  growth,  the  size  of  a  dime,  high  up  on 
forehead  at  border  of  hair.  This  growth  shows  distinct  evi- 
dence of  malignancy  in  a  raised  base  abundantly  supplied  with 
vessels.     Minor  application,  7  ma.  for  30  minutes. 

April  22,  1909.  Patient  visits  office,  showing  no  sign  of  the 
disease  in  either  locality. 

No.  307.  Oncologic  Hospital.  Epithelioma  of  Scalp. — 
T.  J.  O.,  aged  80,  applied  at  dispensary  February  5,  1906, 
with  the  growth  shown  in  the  photograph.  Fig.  28.  It  had 
appeared  eighteen  months  before,  and  had  given  rise  to  no 
sensation  until  within  two  or  three  months,  when  pricking 
sensations  and  itching  developed.  As  the  patient  was  quite 
feeble  it  was  decided  to  attempt  the  removal  of  the  growth 


no 


Applications  to  the  Face. 


without  general  anesthesia,  a  bipolar  minor  application  being 
used  to  lessen  pain.  A  small  negative  surface  was  therefore 
held  against  the  center  of  the  growth,  with  patient  reclining, 
and  two  small  needles  inserted  into  it  near  the  base.  Eighty 
milliamperes  were  gradually  turned  on  and  maintained  for  45 
minutes.    After  resting  the  patient  went  home.    A  microscopic 


Fig.  28. — Case  307  before  treatment,  February  5,  igo6. 


examination  showed  the  tumor  to  be  a  squamous-celled 
epithelioma. 

February  15,  1906.  Slough  came  away.  Wound  dressed 
with  diluted  zinc  ointment. 

March  15,  1906.  Wound  healed  and  showed  no  evidence 
of  disease. 

December  6,  1907.  Msits  dispensary,  showing  no  evidence 
of'disease.     A  photograph,  Fig.  29,  was  taken  at  this  time. 

No.  328.  Oncologic  Hospital.  Rodent  Epithelioma  of 
Forehead. — Mrs.  J.  S.  C,  aged  56,  was  admitted  to  the  dis- 
pensary March  29,  1906,  with  a  patch  of  rodent  epithelioma 
over  left  eye  covering  about  one-third  of  forehead,  superficial, 
with  several  areas  that  had  cicatrized   under   Dr.   Hartzell's 


Applications  to  tJie  Face. 


Ill 


treatment.  A  spot  at  outer  canthus  of  eye  threatens  invasion 
of  the  orbit. 

She  was  placed  under  minor  ionic  applications,  4  ma. 
with  4  needles,  and  attended  dispensary  irregularly  for  6 
months,  at  end  of  which  time  there  was  but  little  disease  evi- 
dent, and  that  attacking  outer  canthus  of  eye  quite  healed 
over. 

February  18,  1908.  Patient  returns  with  distinct  relapse 
except  at  the  corner  of  eye.  As  the  x-ray  had  not  been  tried 
on  this  case,  she  was  referred  to  Dr.  Newcomet. 


Fig.  29. — Case  307  after  one  bipolar  application.     Photograph  taken 
one  year  and  ten  months  later. 

No.  42.  Oncologic  Hospital.  Rodent  Epitheliomu  of  Face, 
Recurrent. — Mrs.  Z.  R.,  aged  50,  was  referred  by  Dr.  Addinell 
Hewson,  May  5,  1906.  The  patient  had  been  admitted  to  the 
hospital  one  year  before  and  the  disease,  then  recurrent,  had 
been  excised.  It  had  existed  three  years  before  admission  to 
Dr.  Hewson's  service,  and  had  resisted  various  methods  of 
treatment.  X-ray  treatment  had  been  used  for  a  time  after 
excision. 


112 


Applications  to  the  Face. 


On  date  above  mentioned  a  major  monopolar  application  of 
200  ma.  was  made  under  general  anesthesia.  Some  nodules 
of  disease  remaining  after  healing,  the  patient  was  placed 
under  minor  ionization  treatment  in  the  dispensary,  from 
I  to  3  ma.  each,  varied  by  three  re-admissions  to  the  hospital 
for  major  applications  varying  in  strength  from  25  to  100  ma. 
Patient  still  under  observation  and  occasional  treatment. 

No.  347.  Oncologic  Hospital.  Epithelioma  of  Cheek. — 
Jas.  O'D.,  aged  70,  was  admitted  July  10,  1906,  with  the  large 
fungating  growth  shown  in  Fig.  30.     The  growth  began  six 


r 


1 


\ 


'-^-ifl^. 


Fig.  30. — Case  347  before  treatment,  July  10,  1906. 

years  before,  and  has  rapidly  grown  during  the  past  year,  in 
spite  of  x-ray  treatment  persistently  applied  for  nine  months. 
Unfavorable  prognosis  had  been  given  by  several  prominent 
surgeons,  who  declined  to  operate.  The  microscopic  exami- 
nation showed  squamous-celled  epithelioma.  The  patient's 
arteries  were  rigid,  and  his  general  condition  indicated  senile 
degeneration. 

July  II.  The  patient  was  placed  under  general  anesthesia 
and  a  bipolar  major  application  made  of  500  ma.  for  50  min- 
utes. 

August  21.     Minor  application  of  18  ma.  to  suspicious  spot. 

August  23.  Discharged  from  hospital  to  dispensary,  with 
dead  bone  showing  (Fig.  31). 


Applications  to  the  Face. 


113 


Fig.  31. — Case  347  after  one  major  application.    Dead  bone  showing  in 
photograpli  taken  August  22,,  1905. 


Fig.  32. — Case  347  after  separation  of  bone  and  final  healing.     Photo- 
graph taken  one  3'ear  and  three  months  after  treatment. 


114 


Applications  to  the  Face. 


Fig.  S2. — Case  364  before  treatment,  June  12,  1906. 


Fig.  34. — Case  364  after  one  dispensary  application.     Photograph  taken 
five  months  later. 


September  15.  Dead  bone  removed.  Edges  of  wound 
healthy. 

December  2,  1907.  Photograph  taken  (Fig.  32),  showing  no 
evidence  of  disease. 


Applications  to  the  Face.  115 

No.  364.  Oncologic  Hospital.  Probable  Epithelioma  of 
Cheek. — Robert  T.,  aged  65,  was  brought  to  the  dispensary 
by  Dr.  J.  E.  Hurff,  of  Blackwood,  N.  J.,  June  12,  1906.  The 
growth  (Fig.  33)  had  been  increasing  gradually  in  size  since 
its  first  appearance,  ten  months  before.  Under  local  cocaine 
anesthesia  a  minor  application  was  made  reaching  80  milli- 
amperes,  3  needles,  for  45  minutes.  No  further  treatment 
was  required,  the  photograph  (Fig.  34)  being  taken  5  months 
later.  No  recurrence  reported  in  letter  dated  December  7, 
1907. 

No.  354.  Oncologic  Hospital.  Epithelioma  of  Fore- 
head.— Mr.  S.  O.,  aged  67,  clerk,  admitted  to  hospital  Septem- 
ber 26,  1906.  Four  years  ago  the  growth  shown  in  Fig.  35 
began,  apparently  as  a  result  of  a  slight  injury.  A  caustic 
plaster  applied  by  an  irregular  practitioner  two  years  later 
caused  increased  and  more  rapid  growth.  A  specimen  on  ex- 
amination was  pronounced  squamous-celled  epithelioma. 

September  26,  1906.  Major  bipolar  application  under  gen- 
eral anesthesia,  of  500  to  600  milliamperes  for  25  minutes. 

October  12.  Slough  removed,  showing  fibers  of  temporal 
muscle  partly  involved. 

October  25.     Discharged  from  hospital. 

October  20,  1909.  Patient  reports  at  hospital  by  request, 
showing  no  evidence  of  disease.  The  photograph,  Fig.  36, 
was  taken  at  this  time. 

No.  369.  Oncologic  Hospital.  Recurrent  Epithelioma  of 
Cheek. — M.  E.  D.,  aged  74,  was  admitted  to  hospital  July  6, 
1906,  with  a  growth  beneath  the  left  eye  recurrent  five  years 
after  removal  by  excision,  which  was  done  over  six  years  ago. 
The  growth  was  in  the  scar,  and  was  about  2x2  cm.  in  size. 
Microscopic  examination  negative. 

July  7,  1906.  ]\Iajor  monopolar  application,  200  ma.  for  25 
minutes. 

July  24.     Slough  removed. 

August  3.     Discharged  from  hospital. 

December  12,  1907.  Reports  in  letter,  by  request,  that  the 
scar  is  healthy  and  shows  no  evidence  of  disease. 

No.  399.  Oncologic  Hospital.  Epithelioma  of  Fore- 
head.— Mrs.  M.  C,  aged  'J2,  was  referred  to  the  hospital  from 
the  Camden  (N.  J.)  Almshouse,  July  24,  1906,  by  Dr.  J.  E, 
Hurff.     There  was  a  large,  fungating  growth  on  the  upper 


Ii6  AppUcaiions  to  the  Face. 

portion   of  the   forehead,   about   the   right   eye.     Her  general 
health  was   poor.     jMicroscopic   examination :   carcinoma. 

August  I,  1906.     i\Iajor  bipolar  application,  500  ma.  for  30 
minutes. 


Fig.  35. — Case  354  before  treatment,  September  26,   1906. 

August  28.  Discharged  from  hospital  with  outer  table  of 
skull  denuded,  but  general  health  improved.  There  was  no 
evidence  of  disease  remaining. 

December  6,  1907.  Dr.  Hurfif  writes  that  the  patient  devel- 
oped a  growth  of  apparently  similar  character  on  the  left  side 
of  face  and  died  of  an  accidental  fall.  There  was  no  local 
recurrence  on  the  forehead. 

No.  420.     OxcoLOGic  Hospital.     Epitheliouia  of  Skin   of 


Applications  to  the  Face. 


117 


Nose. — Mrs.  C.  Z.,  aged  yy,  was  admitted  August  24,  1906, 
with  a  protruding  growth  on  the  bridge  of  the  nose  about  the 
size  of  a  hazel  nut.  It  had  an  indurated  base  and  had  been 
of  slow  growth  (Fig.  37). 


Fig.  36. — Case  354  after  one  major  bipolar  application,  as  scar  appears 
three  years  later. 


August  24,  1906. — Major  monopolar  application,  150  ma. 
for  25  minutes. 

September  21.     Discharged  from  hospital. 

December  19,  1906.  No  evidence-  of  disease  remaining. 
Photograph   (Fig.  38),  taken  at  this  time. 

No.  426.     Oncologic  Hospital.     Epithelioma  of  the  Face, 


Ii8  Applications  to  the  Face. 

— Mrs.  M.  M.,  aged  y2,  was  referred  by  Dr.  John  A.  Stein- 
wandel,  of  Philadelphia,  September  13,  1906,  with  a  fungating 
growth  about  the  size  of  a  silver  dollar  just  below  the  left 
lower  eyelid.  It  had  existed  for  eight  years,  and  had  grown 
rapidly  during  the  last  six  months. 


Fig.  2>7- — Case  420  before  treatment,  August  24,  1906. 

September  19,  1906.  Major  bipolar  application,  400  ma. 
for  20  minutes,  under  general  anesthesia.  On  separation  of 
the  slough  it  was  seen  that  some  disease  remained  at  the  bottom 
of  the  wound,  and  the  patient  was  placed  on  minor  applica- 
tions of  5  to  10  ma.  daily.  As  she  was  restive  under  these 
applications,  complaining  of  the  pain  they  produced,  a  con- 
sultation of  the  staff  advised  the  use  of  x-rays.  The  latter 
treatment  appeared  to  be  effective  in  the  edges  of  the  growth, 


Applications  to  the  Face. 


119 


but  failed  to  arrest  the  invasion  of  the  orbit,  which  took  place 
some  months  later,  with  apparent  extension  to  the  brain.     In 
this  condition  the  patient  later  committed  suicide  by  leaping*- 
from  the  roof  to  a  brick  pavement. 

No.  437.     Oncologic  Hospital.     Probable  Lupus  of  Face. 
— J.  S.,  aged  48,  was  referred  by  Dr.  G.  H.  Gildersleeve,  of 


Fig.  38. — Case  420  after  treatment,   four  months  later. 


Philadelphia,  September  24,  1906,  with  an  indolent  ulceration 
on  the  cheek,  below  the  inner  canthus  of  left  eye.  It  had 
raised,  indurated  edges,  was  about  the  size  of  a  penny,  and  had 
been  first  noticed  eighteen  months  before.  Various  caustic 
applications  had  been  used  ineffectually.  Eight  minor  applica- 
tions of  20,  decreasing  to  4  milliamperes,  were  made,  and  the 
patient  discharged  without  manifest  evidence  of  disease. 

December  9,  1907.     Patient  reports  at  dispensary  by  request, 
showing  no  evidence  of  recurrence. 


120  Applications  to  the  Face. 

No.  86,  Private  Case  Book.  Epithelioma  of  Cheek,  Pene- 
trating Mouth  Cavity.— Mrs.  H.  L.,  aged  85,  was  referred  by 
Dr.  W.  H.  Walling,  of  Atlantic  City,  N.  J.,  September  30, 
1906.  A  daughter  had  recently  died  of  cancer  of  the  breast. 
Twenty  years  ago  a  growth  appeared  in  the  middle  of  the 
left  cheek,  and  it  has  gradually  increased  since.  Three  months 
ago  it  penetrated  the  mouth  cavity. 

There  is  an  opening  through  the  cheek  into  the  mouth,  4/2 
cm.  long  by  3>4  wide,  with  proliferating,  indurated  edges.  No 
enlarged  glands  can  be  found  in  the  neck,  and  the  disease  has 
not  spread  more  than  two  or  three  centimeters  from  the  edges 
of  the  opening.  The  patient  is  in  good  health  considering  her 
advanced  years.  Microscopic  examination  showed  squamous- 
cell  epithelioma. 

September  30,  1906.  A  major  bipolar  application  was  made 
at  the  patient's  residence,  300  to  400  milliamperes  being  used 
for  50  minutes,  under  chloroform.  The  negative  electrode 
was  a  pigeon  egg  shaped  electrode  covered  with  absorbent  cot- 
ton wet  with  dilute  sulphuric  acid  and  held  in  the  opening 
against  the  edges  of  the  growth,  while  the  eleven  needles  used 
were  inserted  just  beyond  its  periphery.  The  patient  t)ore  the 
operation  well,  the  slough  coming  away  in  ten  days. 

December  4.  The  edges  of  the  wound  appear  healthy,  but 
there  is  an  area  above  it,  between  the  left  eye  and  ear,  which 
is  indurated.  This  area  is  about  the  size  of  a  quarter.  A 
second  bipolar  application  was  made  to-day  to  this  area,  100 
to  300  ma.  being  used  for  35  minutes,  with  ten  needles. 

The  slough  of  the  second  operation  came  away  leaving  a 
healthy  wound,  succeeded  by  a  healthy  scar.  The  further  his- 
tory of  the  original  wound  is  as  follows :  During  1907  and  to 
date  of  writing  in  1909  the  wound  has  continued  to  contract 
until  now  it  is  but  2  cm.  long  and  a  mere  slit  in  width;  its 
edges  are  healed  over  in  the  main,  and  there  is  no  odor  or  dis- 
charge. To  combat  distinct  evidences  of  recurrence  in  the 
edge  next  the  ear  she  received  seven  minor  applications  in  1907 
and  four  in  1908,  averaging  5  to  7  milliamperes.  Treatment 
finally  abandoned  owing  to  her  feebleness^ 

No.  442.  Oncologic  Hospital.  Probable  Epithelioma  of 
Skin  of  Nose. — Mrs.  H.  K.,  aged  70,  was  referred  to  dispen- 
sary by  Dr.  E.  H.  Farlow,  of  Laurel,  Dela.,  October  i,  1906, 
with  a  small  growth  on  the  bridge  of  the  nose.     One  minor 


Applications  to  the  Face.  I2I 

application  of  9  milliamperes  for  15  minutes  was  made  on 
above  date.  Patient  reported  at  dispensary  November  25, 
1907,  with  perfect  scar. 

No.  467.  Oncologic  Hospital.  Small  Epithelioma  of  Eye- 
lid.— Mrs.  O.,  aged  44,  referred  by  Dr.  Ladd,  of  Towanda, 
Pa.,  November  21,  1906.  Six  months  before  a  small  growth 
was  noticed  on  the  conjunctival  border  of  lower  right  eyelid. 
On  admission  the  lump  was  found  to  be  about  the  size  of  a 
grain  of  wheat,  with  raised  indurated  base.  It  had  grown 
rapidly  during  the  past  month.  On  above  date  3  ma.  was 
applied  with  two  needles  for  half-hour. 

December  17,  1906.  Some  of  the  disease  remains.  One 
milliampere  for  20  minutes,  two  needles. 

December  9,  1907.  A  remnant,  size  of  small  bird-shot,  re- 
mains; 2>4  milliamperes  for  25  minutes. 

No,  473.  Oncologic  Hospital.  Recurrent  Rodent  Epithe- 
lioma of  Bridge  of  Nose.— Mrs.  S.  R.,  aged  47,  admitted  No- 
vember 20,  1906.  The  growth,  which  was  an  excavated  ulcer 
with  raised  edges  about  2  cm.  in  diameter,  was  situated  on 
the  bridge  of  the  nose.  It  had  first  appeared  three  years 
before,  and  had  been  partly  destroyed  by  arsenical  paste  18 
months  before  admission. 

Major  monopolar  application  November  26,  1906,  25  ma. 
for  15  minutes. 

August  28,  1907.  Minor  application  of  2  ma.  for  10  min- 
utes. 

March  19,  1908.  Called  at  hospital,  showing  no  evidence 
of  disease. 

No.  483.  Oncologic  Hospital.  Small  Incipient  Epithe- 
lioma of  Eyelid.— C.  C.  H.,  aged  39,  admitted  to  dispensary 
December  3,  1906,  with  a  painless  growth  on  conjunctival 
border  of  lower  right  eyelid  about  size  of  a  split  pea.  It  had 
an  indurated,  raised  base,  with  numerous  blood  vessels.  It 
was  not  painful,  had  existed  two  months,  and  was  slowly  in,- 
creasing  in  size.  On  admission,  i>4  milliamperes  for  10 
minutes,  i  needle. 

January  i,  1907.     Five  ma.  for  10  minutes. 
January  19,  1907.     Five  ma.  for  10  minutes. 
No.  87,  Private  Case  Book.    Senile  Epithelioma  of  Skin  of 
Nose.—B-.  C,  aged  82,  was  referred  by  Df.  J.  Gaunt  Edwards, 
of  Williamstown,  N.  J.,  December  2,  1906.     His  mother  had 


122 


Applications  to  the  Face. 


cancer  of  the  shoulder.  For  i8  months  he  had  had  a  scabby 
growth  on  the  tip  of  the  nose.  Eight  months  ago  a  raised  and 
indurated  base  about  the  size  of  a  dime  appeared  beneath  the 
scab. 

December  8,  1906.  Minor  appHcation,  5  to  6  ma.  for  one 
hour. 

June  10,  1909.  Patient  visits  office  with  perfect  scar,  and 
no  recurrence. 

No.  509.  Oncologic  Hospital.  Epthelioma  of  Forehead 
and  Upper  Eyelid. — Jas.  J^.,  aged  58,  railroad  foreman,  was 


Fig.  39. — Front  and  rear  views  of  case  529  before  treatment, 
March  30,   1907. 

referred  by  Dr.  Alex.  P.  O'Malley,  of  Wilkes  Barre,  Pa., 
July  7,  1906.  Six  or  more  years  before  he  had  been  wounded 
in  the  forehead  by  a  hot  coal  from  the  smokestack  of  a  locomo- 
tive; a  growth  appearing  later  in  the  unhealed  wound.  Dr. 
O'Malley  had  treated  the  growth  with  caustics  and  fuming 
nitric  acid,  with  some  benefit,  but  patient  had  been  irregular 
in  attendance.  Bipolar  electrolysis  had  recently  been  used  by 
Dr.  O'Malley. 

July  8,  1906.  Major  monopolar  application,  150  milliam- 
peres,  30  minutes,  to  supra-orbital  region.  Palpebral  portion 
left  for  minor  applications  owing  to  nearness  of  eye- 
ball. 


Applications  to  the  Face. 


123 


During  July  and  August  twenty-two  minor  applications 
made  of  5  to  10  milliamperes  for  30  minutes  each. 

October  2,  1906.  Patient  sent  home  temporarily,  greatly 
improved. 

February  4,  1907.     Readmitted  for  minor  applications. 

September  22,  1907.  Patient  went  home  against  advice. 
Minor  applications  had  so  far  failed  to  eradicate  disease  close 
to  eye,  but  supra-orbital  region  remains  free  of  disease.  X-ray 
advised  at  his  home. 


Fig.  40. — Views  of  case  529   four  months  later. 

No.  529.  Oncologic  Hospital.  Multiple  Recurrent  Epithe- 
liomas of  Face,  Ear,  and  Neck.— I.  P.,  aged  45,  referred  by 
Dr.  Williams,  of  Danville,  111.,  March  30,  1907,  with  the  mul- 
tiple epitheliomas  beneath  each  eye,  at  the  side  of  the  nose, 
behind  each  ear,  and  in  the  neck,  shown  in  Fig.  39.  The 
growths  were  first  noticed  twelve  years  before,  and  those 
beneath  the  eyes  had  been  removed  ten  years  ago,  ineffec- 
tually. 

The  lower  lids  of  both  eyes  had  been  destroyed,  the  growth 
extending  into  the  orbit  of  right  eye  beneath  the  conjunctiva. 


124  Applications  to  the  Face. 

But  little  normal  tissue  remained  in  one  ear.  There  were 
other  nodes  of  growth  about  face  and  neck  of  small  size, 
totaling  12  or  13  separate  centers  of  growth. 

A  microscopic  examination  showed  the  growths  to  be 
squamous-celled  epithelioma. 

April  I,  1907.  Major'  monopolar  application  under  ether. 
With  several  points  in  growth  beneath  right  eye  the  current 
was  brought  up  to  250  milliamperes,  some  needles  being  later 
transferred  to  growth  beneath  left  eye,  while  the  current  was 
gradually  raised  to  400  milliamperes.  With  careful  watching 
no  spot  received  too  much  current.  Later,  during  the  applica- 
tion, the  needles  were  transferred,  one  at  a  time,  to  other  foci, 
during  a  total  monopolar  application  of  i  hour  and  20  min- 
utes. A  bipolar  application  of  400  to  700  milliamperes  for 
26  minutes  was  then  made  to  the  growths  back  of  the  ears, 
beneath  the  nose,  and  on  the  neck. 

During  May  and  June  the  patient  received  six  minor  appli- 
cations to  smaller  centers  of  growth  not  reached  in  the  major 
application,  with  currents  varying  from  3  to  8  milliamperes 
for  a  half-hour  each,  and  Dr.  McClary  made  a  plastic  opera- 
tion to  improve  the  appearance  of  the  left  ear. 

Augi-ist  16,  1907.  Discharged  without  manifest  evidence  of 
disease.  The  photographs  shown  in  Fig.  40  were  taken  at 
this  time. 

December  22,  1907.  Letter  received  from  patient  states 
that  there  is  no  evidence  of  disease  recurring. 

August  16,  1908.  Patient  returns  for  treatment  of  a  minute 
recurrence  in  inner  canthus  of  right  eye  and  on  the  back,  in 
scar  shown  in  Fig.  40.    All  other  scars  healthy. 

No.  542.  Oncologic  Hospital.  Senile  Epithelioma  of  Skin 
of  Face. — B.  R.  B.,  aged  78,  was  referred  by  Dr.  Glenn,  of 
Berwick,  Pa.,  April  18,  1907,  with  several  scaly  epitheliomata 
on  the  right  side  of  the  face.  They  had  been  present  for 
twenty  years,  and  had  resisted  caustic  applications. 

April  18,  1907.  Minor  application  of  10  milliamperes  for 
30  minutes. 

May  4,  1907.  Minor  application,  3  milliamperes  for  30 
minutes. 

May  21,  1907.     Discharged  temporarily. 

December  3,  1907.  Reports  by  letter  that  one  spot  size  of 
pea  still  persists. 


Applications  to  the  Face.  -  125 

February  3,  1908.  Readmitted  with  recurrence  size  of  a 
split  pea.  Minor  application,  3  milliamperes  for  40  minutes. 
No.  546.  Oncologic  Hospital.  Recurrent  Epithelioma  of 
Face. — J.  M.,  aged  y6,  admitted  to  dispensary  April  22,  1907, 
with  a  granular  recurrence  about  scar  of  wound  made  in  oper- 
ation for  removal  of  growth  near  left  angle  of  mouth.  The 
growth  was  of  twelve  years'  duration,  and  had  been  removed 
at  two  local  hospitals.  It  had  been  increasing  somewhat  rap- 
idly during  the  past  year. 

During  April,  May,  June,  and  August,  1907,  the  patient  re- 
ceived twenty-six  minor  applications  (with  2  or  more  needles) 
of  2  to  10  milliamperes  for  30  minutes  each.  The  treatment 
was  painful  on  account  of  the  superficial  nature  of  the 
growths,  and  when  it  had  been  decided  to  resort  to  x-ray 
applications  the  patient  abandoned  treatment,  somewhat  im- 
proved. 

No.  555.  Oncologic  Hospital.  Small  Epithelioma  of  Skin 
of  Face. — Mrs.  M.  A.  W.,  aged  55,  was  referred  by  Dr.  G. 
Oram  Ring,  of  Philadelphia,  May  13,  1907,  with  a  scaly  epi- 
thelioma just  beneath  left  eye  about  the  size  of  a  grain  of 
wheat.  It  had  been  under  x-ray  treatment  for  a  year  at  the 
Episcopal  Hospital,  the  original  size  having  been  i^  cm. 
The  improvement  had  ceased  on  contraction  to  its  present 
dimensions. 

May  13,  1907.     Minor  application,  2  ma.  for  25  minutes. 

March  7,  1908.  Patient  reported  at  hospital  by  request. 
No  evidence  of  disease  to  be  found. 

No.  89,  Private  Case  Book.  Epithelioma  of  Inner  Canthus 
of  Right  Eye. — R.  H.,  aged  76,  was  referred  by  Dr.  C.  A. 
Grofif,  of  Philadelphia,  May  20,  1907.  The  erosion,  with  in- 
durated edges,  shown  in  Fig.  41,  had  been  first  noticed  two 
years  ago,  and  had  resisted  ordinary  treatment. 

May  20,  1907.  Minor  application,  20  milliamperes  for  ]/>, 
hour,  4  needles. 

September  10,  1908.  Patient  visits  office  by  request,  with 
excellent  wound.  The  photograph.  Fig.  42,  was  taken  at  this 
time. 

May  20,  1909.     Patient  reports,  with  no  return  of  disease. 

No.  582.  Oncologic  Hospital.  Recurrent  Epithelioma  of 
Skin  of  Nose. — Mrs.  A.  B.  C,  aged  45,  was  referred  to  dis- 
pensary by  Dr.  G.  H.  West,  of  Philadelphia,  with  a  scar  on 


126 


Applications  to  the  Face. 


the  side  of  the  nose  with  edges  in  which  nodular  masses  were 
evident.  An  attempt  had  been  made  by  the  patient  to  have 
the  growth  removed  by  caustics. 


Fig.  41. — Case  89  before  treatment. 


Fig.  42. — Case  89  one  year  and  four  months  later. 


June  27,    1907.     Minor  application,  4  milliamperes   for  20 
minutes. 


Applications  to  the  Face.  i2y 

June  27,  1907.     Minor  application  2J/2  ma.  for  15  minutes. 

June  3,  1909.  Patient  reports  at  office,  with  no  return  of 
disease. 

No.  606.  Oncologic  Hospital.  Recurrent  Epithelioma  of 
Face. — O.  B.,  aged  73,  was  admitted  from  the  Soldiers'  and 
Sailors'  Home  at  Erie  Pa.,  August  30,  1907,  with  a  large 
growth  on  the  left  side  of  the  face.  The  patient  had  a  caustic 
paste  applied  to  an  epithelioma  of  the  upper  lip  one  year  before, 
the  present  growth  appearing  only  two  months  ago.  It  has 
grown  rapidly  during  the  last  two  weeks.  The  patient  is 
feeble,  and  suffers  from  locomotor  ataxia. 

A  microscopic  examination  showed  the  growth  to  be  an 
epithelioma. 

September  3,  1907.  Major  bipolar  application,  1,100  milli- 
amperes  for  10  minutes. 

September  24,  1907.  Second  major  bipolar  operation,  900 
to  1,100  ma.  for  18  minutes. 

October  7  to  30,  1907.  Fourteen  minor  applications  have 
been  made  to  remnants  of  disease,  30  to  40  milliamperes  each, 
for  30  minutes. 

November  i,  1907.  Third  major  bipolar  operation,  1,200 
to  1,400  ma.  for  20  minutes. 

December  2  to  18.  Five  minor  applications.  The  patient 
developing  evidences  of  pulmonary  tuberculosis  was  referred 
to  Dr.  Codman  of  the  hospital  staff.  He  died  January  3, 
1908.  The  autopsy,  made  by  Drs.  McClary  and  Codman,  re- 
vealed a  cavity  in  right  lung,  the  size  of  a  hen's  egg,  with  old 
adhesions. 

No.  607.  Oncologic  Hospital.  Probable  Lupus  of  Face. 
— W.  H.,  aged  69,  was  admitted  from  the  Soldiers'  and  Sailors' 
Home  at  Erie,  Pa.,  August  30,  1907,  with  an  indolent,  infil- 
trated growth  of  the  skin  of  the  right  temple  the  size  of  a 
silver  quarter.  It  had  existed  five  years,  and  resembled  lupus 
in  clinical  features. 

September  3,  1907.  Major  monopolar  application,  100  to 
200  milliamperes  for  30  minutes,  with  5  needles. 

November  2,  1907.     Discharged  with  healthy  scar. 

No.  92,  Private  Case  Book.  Small  Squamous-Celled  Epi- 
theliomas of  Face. — P.  S.,  aged  38,  ironworker,  applied  No- 
vember 12,  1907,  with  a  small,  raised  growth  on  right  cheek 
about  the  size  of  a  pea,  with  overlying  crust  and  raised  base. 


128 


Applications  to  the  Face. 


Specimen  removed  b}  scissors  and  minor  application  of  15 
ma.  for  16  minutes,  six  fine  needles,  under  local  use  of  cocaine. 

Microscopic  examination :  epithelioma. 

August  10,  1909.  Msited  office  with  healthy  scar,  and  no 
recurrence. 

No.  653.  Oncologic  Hospital.  Rodent  Epithelioma  of  Inner 
Canthus  of  Eye. — J\Irs.  M.  R.,  aged  Gj,  was  referred  by  Dr. 
J.  Gaunt  Edwards,  of  Williamstown,  N.  J.,  November  23, 
1907.  The  growth  was  a  characteristic  rodent  cancer  of  the 
inner  canthus  of  the  left  eye   (Fig.  43),  about  the  size  of  a 


Fig.  43. — Case  653   befurc   ircauneiit,   Xovember  23.   1907. 

copper  cent,  and  had  existed  for  8  years.  No  previous  treat- 
ment had  been  employed. 

A  microscopic  examination  showed  the  growth  to  be  a 
squamous-celled  epithelioma. 

November  25,  1907.  Major  monopolar  application  under 
chloroform.  Fifty  to  sixty  milliamperes  were  used  for  20 
minutes,  with  5  needles ;  then  25  milliamperes  for  10  minutes 
longer. 

November  30,  1907.  Photograph  (Fig.  44)  taken,  show- 
ing slough  in  position. 


Applications  to  the  Face. 


129 


Fig.  44. — Patient  shown  in  Fig.  43  five  days  later,  showing 
slough   in   position. 


Fig.  45. — Patient  sliown  in  Fig.  43  as  part  appears  two  years  later. 


I30 


Applications  to  the  Face. 


December  5,  1907.  Discharged  with  wound  in  good  condi- 
tion. 

January  23,  1908.  Photograph  (Fig.  45)  taken,  showing 
complete  healing. 

November  26,  1909.  Patient  visits  office  with  healthy 
wound  and  no  evidence  of  recurrence.  Dr.  Ring  finds  nasal 
duct  closed. 

No.  709.     Oncologic  Hospital.     Endothelioma  of  Eyelids 


Fig.    46. — Endothelioma    of    eyelids.     Case    709    before 
treatment. 

at  Inner  Canthus. — B.  W.,  aged  64,  was  admitted  from  Sey- 
mour, Indiana,  March  12,  1908.  Of  negative  personal  and 
family  history,  and  excellent  general  health,  the  present  growth 
was  noticed  eleven  years  ago,  having  increased  more  rapidly 
during  the  past  four  years. 

Examination  shows  a  proliferating,  ulcerating  growth  at  the 
inner  canthus  of  the  right  eye  (Fig.  46),  with  three  exten- 
sions: towards  the  bridge  of  the  nose,  and  in  either  eyelid. 
The  nasal  extension  and  that  in  the  lower  eyelid  were  ulcer- 
ated. The  conjunctiva  is  superficially  hazy,  and  the  upper 
lid  could  not  be  raised  voluntarily  above  the  pupil.     Dr.  Swan 


Applications  to  the  Face. 


131 


reported  as  follows  of  a  specimen  removed  before  operation: 
The  tumor  is  composed  of  collections  of  cells  around  trabeculse 
of  connective  tissue  containing  blood  vessels.  The  cells  vary- 
in  shape  and  size,  the  majority  of  them  looking  like  large 
round  cells,  a  few  like  spindle  cells.  In  places  the  tumor 
shows  blood  spaces  of  varying  size,  some  with  and  some  with- 
out an  endothelial  wall.  In  other  parts  of  the  growth  there 
are  distinct  hemorrhagic  areas.     Diagnosis :  endothelioma. 

Operation. — March  12,  1908.  Monopolar  application  of  150 
milliamperes  for  50  minutes,  with  3  to  8  fine  zinc-mercury 
needles,  under  general  anesthesia,  care  being  observed  to  limit 


Fig.  47. — Case  709  one  year  after  treatment. 


the  ionic  destruction  strictly  to  the  diseased  tissue.  The  eye 
was  dressed  with  boric  acid  solution  immediately  after  the 
operation. 

Inspection  the  next  day  showed  that  the  eyeball  was  in  a 
healthy  condition  and  the  diseased  parts  well  devitalized.  On 
the  17th  the  boric  acid  solution  was  changed  to  a  drop  of 
atropine  solution,  14  gr.  to  oz.,  washed  out  ten  minutes  later 
by  10  per  cent,  argyrol  solution  twice  a  day.  -April  4  the 
boric  acid  solution  compress  was  changed  to  20  per  cent,  zinc 
oxide  ointment.  On  April  9  the  slough  came  away,  showing 
an  excellent  condition  except  in  the  nasal  side  of  the  wound, 
where  doubtful  granulations  received  minor  applications  of  5 


132 


Applications  to  the  Face. 


to  10  milliamperes  on  six  occasions  during  the  remainder  of 
April ;  of  I  to  3  milliamperes  on  seven  occasions  during-  May ; 
of  4  milliamperes  on  one  occasion  in  June;  and  of  2  milliam- 
peres each  on  one  occasion  each  in  July,  August  and  Septem- 
ber. After  the  latter  he  returned  to  his  home,  without  mani- 
fest evidence  of  disease. 

February  3,  1909.  Letter  received,  inclosing  photograph 
(Fig.  47),  taken  just  previously.  The  patient  states  that  the 
eyelids  can  be  opened  and  closed  at  will,  and  that  the  sight  is 


Fig.  48. — Epithelioma  of  face  before  ionic  treatment.     Case  Xo.  763. 


excellent.  There  is  no  sign  of  recurrence.  A  further  report 
in  November,  1909,  states  there  is  no  sign  of  a  return  of  the 
growth. 

No.  719.  Oncologic  Hospital.  Recurrent  Epithelioma  of 
Skin  of  Nose. — Mrs.  A.  H.,  aged  82,  was  admitted  March  23, 
1908.  Ten  years  ago  she  first  noticed  a  growth  on  the  ala  of 
the  left  nostril.  It  has  been  removed  twice  by  excision,  the 
last  operation  having  been  done  one  year  ago. 

The  left  ala  of  the  nose  has  been  removed.  Extending  up- 
wards from  the  scar,  there  is  a  large  ulcerated  area  about  the 
size  of  a  one  cent  piece,  covered  with  a  thick  dry  crust. 


Applications  to  the  Face.  133 

Under  consultation  the  x-ray  treatment  was  advised,  as 
less  painful  for  the  aged  patient.  She  was  therefore  referred 
to  Dr.  Newcomet,  who  removed  the  crust  after  applying  a 
poultice  of  green  soap,  and  began  x-ray  treatment  in  10  min- 
ute sittings  at  10  inches.  Forty-nine  applications  of  the  rays 
were  made  between  the  date  of  admission  and  June  22,  at 
which  time  she  was  sent  home  to  give  time  for  the  effect  of 
the  rays  to  fully  develop.  At  this  time  the  ulceration  was  bet- 
ter, with  but  a  few  patches  left.  A  boric-bismuth-lanolin  oint- 
ment was  prescribed. 

October  20,  1908.     Patient  referred  back  to  author  by  Dr. 


Fig.  49. — Case  763   one  and  a  half  years  after  treatment. 

Newcomet,  with  central  portion  of  the  scar  showing  an  ulcer- 
ation 2  cm.  long.  With  cocaine  dropped  on  the  part  she  was 
well  able  to  stand  a  current  of  5  ma.  for  thirty  minutes.  The 
subsequent  treatments  were  as  follows :  November  10,  4  ma. 
for  30  minutes;  November  17,  i>^  for  half  hour;  November 
20,  2  for  20  minutes;  November  23,  i^^  for  20  minutes;  De- 
cember 2,  i^  for  15  minutes;  December  8,  i^^  for  15  min- 
utes; December  10,  ij^  for  15  minutes;  December  13,  i^^  for 
15  minutes;  January  7,  1909,  i  ma.  for  15  minutes;  January 
14,  ^  ma.  for  20  minutes.     The  patient  was  discharged  with 


134 


Applications  to  the  Face. 


a  well  healed  scar  February  ii,  1909,  and  reports  no  return 
of  the  disease  in  November,  1909. 

No.  763.  Oncologic  Hospital.  Epithelioma  of  Face. — 
J.  F.  L.,  aged  87,  was  referred  to  the  service  of  Dr.  Codman 
by  Dr.  A.  W.  Ransley  of  Philadelphia,  June  3,  1908.  The 
growth  shown  in  Fig.  48  was  first  noticed  two  years  ago.  It 
had  been  treated  by  caustic  pastes  and  the  x-ray. 

On  the  right  cheek,  at  the  base  of  the  parotid  gland,  there 
is  a  proliferating  epithelioma  with  an  area  equal  to  the  size 
of  a  25-cent  piece  and  projecting  one  inch  above  the  level  of 
the  skin.  The  entire  right  cheek  seems  more  prominent  than 
the  left.  Dr.  Codman  referred  the  patient  to  Dr  Newcomet 
for  x-ray  treatment. 


Fig.  50. — Carcinoma  of  face  before  ionic  treatment.     Case  765. 


July  8,  1908.  Patient  referred  to  the  author  by  Dr.  New- 
comet  for  ionic  treatment.  Minor  application,  17  milliam- 
peres  for  30  minutes.  During  the  remainder  of  the  month 
five  applications  were  made,  decreasing  from  18  milliamperes 
to  10.  During  August  there  were  five  applications,  varying 
from  16  to  6  milliamperes  ;  during  September  eight,  of  10  to  6 
milliamperes ;  and  during  October  one  of  10  milliamperes. 

October  13,  1908.  Patient  discharged  from  further  treat- 
ment with  an  excellent  scar  and  no  sign  of  disease.  The 
photograph,  Fig.  49,  was  taken  at  this  time. 

November  16,  1909.  Patient  visits  dispensary  by  request. 
The  scar  is  fully  as  healthy  and  somewhat  less  visible  than  ap- 


Applications  to  the  Face. 


135 


pears  in  the  second  photograph.  The  patient  is  in  the  best  of 
health,  in  spite  of  his  more  than  88  years. 

No.  765.  Oncologic  Hospital.  Epithelioma  of  Face.^ 
Mrs.  E.  C,  aged  53,  was  referred  by  Dr.  L.  E.  Taubel  of 
Philadelphia,  June  4,  1908.  Two  and  a  half  years  before  she 
had  been  struck  by  a  toy  thrown  by  a  child,  and  the  abrasion 
made  never  healed.  Five  weeks  ago  a  rapid  increase  in  size 
was  noted. 

There  is  a  firm,  nodular  growth  on  the  right  cheek  im- 
mediately below  the  eye,  about  the  size  of  a  flattened  marble 
(Fig.  50).     Pathologic  diagnosis  by  Dr.  Swan:  carcinoma. 

June  9,   1908.     Minor  application  in  dispensary,  20  milli- 


FiG.  51. — Case  765  as  part  appears  one  and  a  half  years  after  treatment. 


amperes  bipolar  for  15  minutes,  changed  then  to  25  milliam- 
peres  for  an  additional  15  minutes,  monopolar,  under  local  co- 
caine. Additional  applications  were  as  follows :  July  2^,  1 1 
ma.  for  30  minutes ;  August  10,  3  ma.  for  30  minutes ;  August 
21  and  24,  2  ma.  for  30  minutes;  September  2,  18,  25  and  29, 
2  ma.  for  30  minutes ;  October  6  and  20,  2  and  3  ma.  for  30 
minutes  each. 

October  27,  1908.  Patient  examined,  showing  no  sign  of 
disease. 

November   12,   1908.     Photograph    (Fig.  51)   taken. 

November  18,  1909.  Patient  visits  dispensary  with  no  sign 
of  recurrence. 


136 


Applications  to  tlic  Face. 


No.  855.     Oncologic  Hospital.     Epithelioma   of  Face. — 
W.  H.   B.,  aged  53,  was  referred  by  Dr.   B.   F.   Coulter  of 


Fig.  52. — Epithelioma  of  face  before  treatment.     Case  855. 


1 

l^^^pT'j 

r  ' 

Hjit 

1 

Rp 

^ 

fS^'i" 

T 

'^jSr 

^^m 

k 

^^^^^^ 

S 

< 

\^!-'l^ 

■BHPa'' 

» 

ftisi*  • 

^f^ 

1 

m 

\ 

oSb^B^B 

$ 

■*  '■.  ;5'  . ' 

Fig.  53. — Case  855  one  j^ear  after  treatment. 


Philadelphia,    December   4,    1908.     A    red    pimple    was    first 
noticed  on  the  left  cheek  four  months  ago,  and  it  has  increased 


Applications  to  the  Face. 


137 


steadily  in  size  since.     It  is  not  tender  and  has  given  no  pain. 

There  is  a  raised,  red  tumor  in  the  middle  of  the  left  cheek, 
i^  cm.  in  diameter  and  projecting  i  cm.  above  the  surface, 
with  indurated  base  (Fig.  52).  Palpation  indicates  that  it  is 
probably  cystic.  Pathologic  examination  by  Dr.  Swan: 
epithelioma. 

December  7,  1908.  Minor  application,  15  to  20  milliam- 
peres  for  50  minutes,  4  needles.  On  puncturing  the  tumor  it 
was  found  to  be  more  solid  than  appeared,  bleeding  freely. 
There  was  no  evidence  of  a  cyst. 

December  30.  Small  slough  has  separated  and  wound 
seems  healthy.  Patient  directed  to  return  once  a  week  for  in- 
spection. 

January  20,  1909.  Patient  discharged  from  dispensary, 
without  manifest  evidence  of  disease. 

February  19,  1909.  Photograph  (Fig.  53)  taken,  showing 
*no  sign  of  recurrence. 

November  17,  1909.  Patient  visits  dispensary,  showing  no 
sign  of  recurrence. 


SUMMARY    OF    SECOND    SERIES    OF    FACE    AND    SCALP    CASES. 


Operable  Cases. 


Without    manifest    evidence 

of  disease  at  prese.jt 

26 


Ameliorated 


Still   under 
treatment 


Failed 


Inoperable   Cases. 


Without    manifest    evidence 
of  disease  at  present 


Ameliorated 


Still   under 
treatment 


Failed 


Died  under 
treatment 


Died  under 
treatment 


Or,  if  the  i  case  still  under  treatment  be  excluded,  together 
with  the  3  showing  "  no  disease  "  diagnosed  as  lupus,  the  cor- 
rected figures  will  show  31  cases  successful  out  of  42,  or  about 
73.8  per  cent. 


CHAPTER  X. 

APPLICATIONS    WITHIN    THE    MOUTH     AND     NOSE. 

The  conditions  attending  malignant  growths  within  the 
mouth  and  nose  render  the  ionic  methods  of  special  value,  for, 
as  remarked  elsewhere,  these  methods  enable  us  to  destroy  the 
peripheries  of  the  growths  by  insulated  electrodes  thrust  into 
them  through  the  natural  opening  of  the  cavity,  the  lips  being 
merely  retracted,  thus  rendering  disfiguring  operations  on  the 
overlying  facial  structures  unnecessary.  In  favorable  cases 
this  enables  us  to  restrict  the  destruction  of  tissue  more  nearly 
to  the  diseased  parts  alone  than  is  possible  with  any  other 
surgical  method,  for  the  ionization  process  is  as  readily  per- 
formed as  curettement,  without  the  wounding  of  living  cancer 
tissues  and  possible  reimplantation  of  living  cells  in  the  edges 
of  the  wound  as  in  the  latter  process. 

Additional  advantages  of  the  ionic  methods  over  excision  in 
some  cases  are:  the  freedom  from  hemorrhage  during  the 
operation,  after  the  bleeding  caused  by  the  removal  of  a  speci- 
men for  biopsy  is  checked,  thus  doing  away  with  the  dangers 
of  inspiration  pneumonia,  and  permitting  a  continuous  and 
clear  view  of  the  site  of  operation  during  the  whole  time  of  its 
performance;  and  the  fact  that  the  impossibility  of  at  times 
securing  an  aseptic  field  of  operation  within  the  mouth  or  nose 
will  not  unfavorably  affect  the  ionic  operation,  permitting  suc- 
cessful results  in  the  presence  of  septic  conditions  of  the  teeth 
and  gums  that  would  militate  against  an  excision  operation. 

The  element  of  danger  attending  ionic  operations  in  mouth 
cases  is  usually  restricted  to  two  factors:  (i),  Too  strong  a 
current  in  a  monopolar  operation — a  danger  eliminated  when- 
ever possible  by  the  employment  of  the  bipolar  technic;  or, 
(2),  secondary  hemorrhage,  from  the  inclusion  of  large  vessels 
in  the  area  of  sterile  destruction.  This  latter  source  of  danger 
may  be  largely  eliminated  by  preliminary  ligation  of  the  ex- 
ternal carotid  or  lingual  artery  on  the  affected  side,  it  being 
possible  at  times  to  do  the  ligation  and  ionic  operation  con- 
secutively under  the  same  anesthetization  if  the  first  named 
operation  is   done  quickly.     In  practice,  the  ligation  may  be 

138 


Applications  Within  the  Mouth  and  Nose. 


139 


neglected  if  the  site  of  operation  presents  an  easy  field  for 
packing  in  the  event  of  hemorrhage. 

This    danger    of    secondary    hemorrhage    is    not    great    in 
growths  of  the  anterior  portion  of  the  mouth,  or,  in  fact,  in  any 


Fig.  53a. — Author's  Ionization  Table,  as  made  by  the  Victor  Electric 
Co.,   for  major  and  minor  ionic  surgery. 

growths  in  the  mouth  cavity  proper,  anterior  to  the  pillars  of 
the  fauces.  The  danger  of  hemorrhage  is  great,  on  the  con- 
trary, in  all  growths  within  the  pharynx  or  in  the  tonsillar 
regions,  unless  the  growth  is  distinctly  superficial,  for  the 
necessity  for  a  thorough  inclusion  of  all  peripheries  of  the 
diseased  area  in  a  complete  operation  makes  the  danger  of 
hemorrhage  in  this  region  a  grave  peril. 


140  Applications  Within  the  Mouth  and  Nose. 

The  situation  of  the  growth  is  therefore  a  ma'tter  of  greater 
importance  in  the  prognosis  of  cases  under  ionic  operations 
than  the  variety,  though  it  should  be  understood  that  the 
virulence  of  the  type  of  disease,  as  measured  by  the  quick- 
ness of  its  growth  since  its  first  appearance,  dictates  the  extent 
of  inclusion  of  surrounding  tissues  necessary  to  a  thorough 
eradication,  with  corresponding  extension  of  risk.  The  pres- 
ence of  infected  glands  in  the  neck,  usually  attending  the 
carcinomas  but  rarely  the  epitheliomas,  is  an  exceedingly  grave 
complication,  the  treatment  of  which  will  be  referred  to  later. 

Major  Operation  Within  the  Mouth. — Having  determined 
that  the  case  is  a  suitable  one  for  possible  eradication  by  this 
method,  and  prepared  the  patient  for  general  anesthesia  as  in 
ordinary  operations,  the  large,  warm  kaolin  pad  with  conduct- 
ing plate  beneath  is  placed  on  the  operating  table  to  act  as  the 
negative  pole  in  case  the  monopolar  method  is  used  at  any  time 
during  the  operation,  and  the  patient  lies  on  the  table  with  the 
pad  beneath  the  back.  Should  these  preparations  be  repugnant 
to  the  patient  when  made  in  his  presence,  the  anesthetic  may 
of  course  be  administered  elsewhere  and  the  patient  be  placed 
in  position  after  full  anesthesia. 

Unless  distinctly  contra-indicated,  the  writer  prefers  chloro- 
form as  the  anesthetic,  preceded  one  hour  before  the  an- 
esthetization by  a  hypodermic  injection  of  one-quarter  of  a 
grain  of  morphia  and  y^g-  gr.  of  hyoscin,  or,  in  some  cases, 
one-half  this  dose,  for  the  reason  that  the  chloroform 
anesthesia  is  accompanied  by  far  less  salivary  secretion  than 
ether  anesthesia,  and  less  chloroform  itself  is  needed  when 
the  hyoscin-morphia  is  used. 

The  active  electrodes,  which  should  be  prepared  well  in  ad- 
vance of  the  operation,  consist  of  slender,  pointed,  zinc  needles, 
4  to  6  inches  (10  to  14  cm.)  in  length  and  made  of  one- 
thirty-second-inch  (i  mm.)  zinc  plate,  one-eighth-inch  (3  mm.) 
wide  and  tapering  to  a  fine  point.  These  are  attached  in  sets 
of  two  or  four  to  suitable  lengths  of  No.  28  cotton-covered 
wire  connected  with  the  positive  pole  of  the  battery  or  Ionic 
Table.  Each  electrode  is  curved  in  a  suitable  manner  to  reach 
the  growth  conveniently  through  the  mouth,  and  is  eft'ectively 
insulated  by  a  thin  coating  of  fused  sealing  wax  so  as  to  leave 
uncoated  only  that  portion  of  the  tip  that  will  be  buried  in  the 
growth.     The  mercury   coating  of   the  active   surface   is   not 


Applications  Within  the  Mouth  and  Nose.  141 

applied  until  immediately  before  their  insertion,  as  it  renders 
them  exceedingly  brittle. 

With  the  patient  under  the  anesthetic,  the  jaws  are  held  apart 
by  a  suitable  instrument  and  the  lips  are  retracted  with  a 
curved  hard-rubber  retractor  on  one  side,  held  by  an  assistant, 
and  on  the  other  by  means  of  a  miniature  lamp  inclosed  in  a 
test  tube  made  of  strong  glass,  the  latter  being  held  by  the 
operator  to  act  as  both  illuminant  and  retractor,  the  glass  cov- 
ering permitting  a  free  use  of  it  for  that  purpose.  Before  pro- 
ceeding further  in  the  operation  a  specimen  is  now  removed 
for  microscopic  examination,  as  none  will  be  available  later, 
and  the  hemorrhage  is  stopped  by  amalgamating  and  inserting 
an  electrode  in  the  cut  surface  and  turning  on  the  current 
without  delay,  either  as  a  bipolar  or  monopolar  operation. 

The  bipolar  method  is  to  be  preferred  in  all  operations  de- 
manding considerable  current,  as  in  this  method  none  of  the 
current  traverses  the  nerves  of  the  neck,  thus  avoiding  em- 
barrassment of  heart  action  and  circulation  during  the  flow  of 
the  current,  and  it  may  be  employed  whenever  there  is  suf- 
ficient substance  in  the  growth  to  enable  us  to  hold  a  small 
spade-shaped  cotton-covered  negative  electrode  against  it  with- 
out touching  the  active  needles.  The  absorbent  cotton  on  this 
electrode  should  be  dipped  in  25  per  cent,  sulphuric  acid  and 
water  to  absorb  the  hydrogen  ions  as  liberated,  additional  acid 
being  added  from  time  to  time  by  means  of  a  glass  dropper. 
When  employing  the  bipolar  method  in  this  way  the  kaolin  pad 
under  the  back  is  not  in  use,  of  course,  a  wire  attached  to  the 
negative  electrode  within  the  mouth  being  connected  directly 
to  the  negative  binding  post  of  the  apparatus. 

Having  amalgamated  and  placed  an  active  electrode  needle 
in  the  wound  produced  in  removing  the  specimen  and  the  nega- 
tive merely  on  the  growth,  a  current  of  100  to  200  milliamperes 
is  gradually  turned  on,  the  mouth  being  kept  free  from  blood 
and  moisture  as  far  as  possible  by  swabbing  with  gauze  sponges 
held  in  hemostats.  In  from  five  to  ten  minutes  all  bleeding 
will  have  ceased,  when  the  field  of  operation  may  be  cleaned, 
additional  zinc-mercury  needles  inserted  in  the  peripheries  of 
the  growth,  and  the  current  increased  to  from  350  to  500  milli- 
amperes. The  remainder  of  the  operation  is  practically  dry, 
and,  being  well  lit  by  the  miniature  lamp,  the  dispersion  of  the 
ions  is  kept  constantly  in  view  until  the  whole  of  the  growth 


142  Applications  Within  the  Mouth  and  A^ose. 

and  its  immediately  surrounding  tissue  is  turned  a  grayish- 
white  in  color,  which  is  a  sign  of  complete  ionic  sterilization. 
The  current  is  then  turned  off  slowly,  and  the  electrodes  are 
removed  for  final  inspection  of  the  field  of  operation,  and,  if 
no  sign  of  living  malignant  tissue  remains,  the  patient  is  put 
to  bed. 

If  the  monopolar  method  only  can  be  used,  the  plate  beneath 
the  kaolin  pad  on  which  the  patient  lies  is  connected  with  the 
negative  pole  and  the  same  technic  is  followed  with  a  weaker 
current,  and  without  the  negative  electrode  within  the  mouth. 

Such  an  operation  for  an  average  growth  will  require  from 
thirty  to  fifty  minutes  for  its  completion.  Owing  to  the  fact 
that  there  is  little  or  no  loss  of  blood,  it  is  never  followed  by 
shock.  To  allay  the  sensation  of  heat  and  burning  that  would 
be  experienced  by  the  patient  on  emerging  from  the  anesthetic 
a  hypodermic  injection  of  morphia  is  directed  to  be  given 
during  the  following  night,  if  needed.  By  morning  the  patient 
is  usually  comfortable  and  suffering  no  pain,  though  the  parts 
present  considerable  tumefaction  and  tenderness. 

During  the  separation  of  the  slough,  which  requires  from  ten 
to  sixteen  days,  but  slight  odor  will  appear  and  that  in  the 
latter  stages  of  the  process.  The  patient  is  made  comfortable 
by  a  weak  mouth  wash  of  some  antiseptic  solution.  Should 
there  appear  to  be  danger  of  hemorrhage  on  separation  of  the 
slough  a  nurse  should  be  in  constant  attendance  between  the 
tenth  and  sixteenth  days  with  a  carbolized  ^lonsell's  Solution 
at  hand,  and  should  bleeding  occur,  pledgets  of  gauze  dipped 
in  the  solution  should  be  packed  down  on  the  bleeding  spot 
and  left  in  place  several  days. 

The  wound  left  on  separation  of  the  slough  is  painless  and 
heals  readily,  usually  with  some  contraction.  Should  the  dis- 
ease have  invaded  the  alveolar  processes  of  the  mandible  or 
maxilla,  or  the  bodies  of  these  bones,  the  diseased  bone  and 
contiguous  parts  will  be  devitalized  by  the  ions  equally  with 
the  soft  tissues,  and  will  separate  also  spontaneously,  the  edges 
left  healing  readily.  This  separation  of  devitalized  bone  will 
require  from  thirteen  to  twenty-six  weeks. 

Major  Operations  Within  the  Nose. — Applications  to 
growths  within  the  nasal  cavities  demand  a  similar  technic,  ex- 
cept that  the  space  within  which  the  application  is  made  is  so 
restricted  that  the  monopolar  method  alone  is  feasible,  with 


Applications  Within  the  Mouth  and  Nose.  143 

currents  varying  between  200  and  300  milliamperes  only. 
But  one  electrode,  or  possibly  two,  can  be  employed.  When 
properly  conducted,  no  injury  need  be  done  to  the  nostrils  or 
other  healthy  structures. 


FIRST  SERIES  OF  CASES. 

Between  1893  and  Januar}^  1905,  the  writer  employed  some 
modification  of  the  methods  outlined  above  in  14  cases  of 
malignant  growths  within  the  mouth,  2  of  which  were  operable 
in  the  ordinary  sense  and  12  inoperable,  most  of  them  hope- 
lessly inoperable.  Of  these,  4  were  cured,  including  the  two 
operable  cases,  3  died  during  or  shortly  after  the  operation,  2 
were  relieved  for  a  long  period  of  time,  but  finally  relapsed, 
and  5  were  failures  to  arrest  the  disease  for  any  length  of 
time.  To  save  space,  the  four  successful  cases  only  of  this 
series  are  reported  in  full. 

Sarcoma  of  Maxilla. — Wm.  O.,  aged  39,  laborer,  applied  for 
treatment  October  11,  1897.  He  was  a  sugar  house  worker  of 
strong  physique,  but  anemic.  Six  months  before,  a  tendency 
of  the  molar  teeth  on  the  right  side  of  the  upper  jaw  to  loosen 
and  fall  out  while  apparently  healthy  had  been  noticed,  and 
attracted  the  attention  of  his  dentist  to  a  growth  in  this  situ- 
ation.    The  tumor  has  grown  rapidly  since. 

Examination  showed  that  four  teeth  were  missing  and  their 
position  occupied  by  a  smooth,  painless  tumor  that  was  4  cm. 
long,  2  cm.  wide,  and  projected  3  cm.  into  the  mouth.  That 
it  replaced  the  bony  tissue  of  the  alveolar  process,  and  ex- 
tended into  the  antrum,  was  made  evident  by  a  distinct  out- 
ward projection  of  the  anterior  wall  of  the  antrum  and  by  a 
flattening  of  the  arch  of  the  hard  palate  on  the  side  correspond- 
ing to  the  growth. 

October  27,  1897.  A  major  monopolar  operation  was  at- 
tempted on  this  date  at  the  patient's  home,  with  the  kind  as- 
sistance of  Dr.  E.  P.  Bernardy,  but  as  the  electrodes  were  too 
short,  the  effort  was  abandoned  after  500  milliamperes  had 
been  used  for  14  minutes.  The  electrodes  employed 
were  of  18  karat  gold,  amalgamated  with  mercury,  and  one 
of  the  difBculties  encountered  was  the  keeping  of  a  sufficient 
quantity  of  mercury  in  contact  with  the  electrodes.  Two 
weeks  later  the  patient  was  placed  on  monopolar  minor  ap- 


144  Applications  Within  the  Mouth  and  Nose. 

plications  at  the  office,  pointed  zinc-mercury  electrodes  being 
now  used,  with  a  current  of  25  to  35  milliamperes  for  thirty 
minutes.  These  applications  were  continued  thrice  weekly  for 
two  months,  when  all  diseased  tissue  had  apparently  been  de- 
stroyed, both  within  the  mouth  and  the  antrum,  the  electrodes 
having  been  inserted  into  the  antral  portion  through  the  sinus 
that  was  formed  by  the  destruction  of  the  growth.  During 
these  applications  a  specimen  of  the  growth  was  removed  for 
microscopic  examination,  showing  it  to  be  a  spindle-celled 
sarcoma. 

November  14,  1898.  The  patient  returns  with  evidence  of 
some  diseased  granulations  within  the  sinus.  Minor  applica- 
tions of  15  to  25  ma.  were  begun  and  continued  once  weekly 
through  the  winter.  About  this  time  the  patient  was  shown 
to  the  Philadelphia  County  Medical  Society.  A  year  later  a 
few  more  minor  applications  were  made  to  redundant  tissue 
within  the  sinus. 

February  25,  1905.  The  patient  returns  in  excellent  condi- 
tion, but  showing  a  ball-valve-like  nodule  of  tissue  springing 
from  the  anterior  side  of  the  sinus,  at  its  entrance  into  the 
antrum,  the  sinus  now  being  only  large  enough  to  admit  the 
bulb  of  a  clinical  thermometer.  The  flattening  of  the  palatal 
arch  has  disappeared,  but  there  is  slight  protrusion  of  the  an- 
terior wall  of  the  antrum,  as  shown  by  greater  prominence  of 
the  cheek  in  this  situation.  Minor  applications  of  5  to  8  ma. 
for  30  minutes  were  made  about  once  a  week,  and  later  once 
a  month,  for  the  following  six  months. 

At  the  present  time  (November,  1909),  twelve  years  after 
the  beginning  of  the  treatment,  the  patient  is  in  excellent 
health,  and  there  is  no  evidence  of  recurrence. 

Recurrent  Epithelioma  of  Buccal  Surface  of  Cheek. — G.  W. 
B.,  carpenter,  aged  59,  was  first  seen  September  7,  1900,  with 
a  proliferating  growth  on  the  inside  of  the  left  cheek,  near 
the  angle  of  mouth,  about  the  size  of  a  quarter,  with  raised 
and  eroded,  surface.  The  growth  was  recurrent  after  partial 
destruction  by  a  caustic  paste,  and  had  been  increasing  in  size 
for  about  a  year. 

September  23,  1900.  Monopolar  operation  under  ether,  200 
milliamperes  for  20  minutes.  The  result  was  but  a  partial 
destruction  of  the  growth,  the  technical  faults  being  probably 
too  large  an  electrode  and  insufficient  time.     The  disease  re- 


Applications  Within  the  Mouth  and  Nose.  145 

maining  was  later  attacked  in  the  office  by  minor  applications 
of  5  to  15  milliamperes  on  several  occasions  during  the  follow- 
ing year,  the  series  of  applications  being  repeated  again  two 
years  later. 

May  17,  1906.  Patient  admitted  to  the  Oncologic  Hospital 
with  a  recurrence  of  the  disease  in  the  alveolar  process  of 
the  mandible  beneath  the  former  site.  A  major  monopolar  ap- 
plication of  zinc-mercury  ions  was  made  under  chloroform, 
350  milliamperes  for  30  minutes,  with  electrode  points  thrust 
into  the  eroded  bone. 

August  14,  1906.  Patient  readmitted  to  the  hospital  for 
treatment  of  suspicious  granulations  that  show  in  cavity  on 
separation  of  a  small  bone  slough.  Fifty  milliamperes  were 
applied  for  20  minutes,  monopolar. 

May  4,  1909.  Patient  returns  by  request,  showing  a  re- 
tracted scar  at  site  of  applications,  with  tongue  drawn  down 
somewhat,  but  no  sign  of  recurrence. 

Epithelioma  of  Gum. — Miss  C.  C.  M.,  aged  37,  was  first 
seen  April  23,  1901,  with  a  small,  smooth  growth  on  the  gum 
above  the  right  canine  tooth.  The  patient  was  referred  to 
Prof.  M.  H.  Cryer  for  diagnosis,  who  pronounced  it  an 
€pithelioma.  As  the  growth  was  quite  small,  a  series  of  nine 
minor  zinc-mercury  ionic  applications  were  made  during  April 
and  May,  varying  from  2  to  5  ma.  under  the  local  injection  of 
a  weak  cocaine  solution.  A  healthy  scar  resulted,  and  the 
patient  reports  by  letter  in  January,  1909,  that  there  has  been 
no  re-growth. 

Sarcoma  of  Gum. — Earl  H.,  aged  6,  was  referred  by  Dr.  F. 
Otis  Bryant  of  Chester,  Pa.,  June  2,  1904.  About  four 
months  previously  a  lower  incisor  tooth  was  extracted.  The 
next  day  a  growth  was  noticed  at  the  site  of  extraction,  which 
has  increased  in  size  to  the  present  time,  when  it  is  about  equal 
to  a  hickory  nut,  growing  on  both  sides  of  an  adjacent  incisor 
and  apparently  springing  from  the  bone.  With  the  assistance 
of  Drs.  Bryant  and  Johnson  a  major  bipolar  application  was 
performed  under  chloroform  on  the  above  date,  350  milli- 
amperes being  applied  with  both  poles  on  the  growth,  and  a 
current  duration  of  20  minutes.  Recovery  was  uneventful. 
Dr.  Bryant  reports  recently  that  he  has  not  heard  of  any  re- 
currence of  the  growth.  Pathologic  report  of  specimen  re- 
moved immediately  before  operation :   Sarcoma   of  the  poly- 


146  Applications  Within  the  Mouth  and  Nose. 

morphous  variety,  showing  chiefly  large  spindle  cells  with  a 
mixture  of  giant  cells. 


SECOND    SERIES. 

(Reported  in  full  as  treated.) 

No.  41.  Oncologic  Hospital.  Epithelioma  of  Lozver 
Jaw. — R.  E.,  aged  62,  laborer,  was  admitted  February  2,  1905, 
with  a  proliferating  growth  springing  from  right  side  of  body 
of  mandible  and  alveolar  process,  all  teeth  behind  incisors  of 
affected  side  having  been  displaced  in  the  progress  of  the 
disease.  The  growth  had  been  first  noticed  six  months 
before,  and  was  growing  rapidly. 

An  attempt  was  made  to  destroy  the  growth  by  minor  ap- 
plications, which  were  too  painful.  On  February  9,  1905,  he 
was  placed  under  chloroform  and  a  bipolar  application  of  100 
to  200  ma.  was  made  to  the  growth  for  one  hour,  followed 
immediately  by  a  monopolar  application  of  100  to  200  ma.  for 
20  minutes.  The  patient  was  discharged  to  the  dispensary 
three  weeks  later,  with  evidence  of  some  disease  remaining, 
and  received  several  minor  applications  of  15  to  30  ma.  until 
May  15,  when,  doubtless  due  to  the  pain  produced  by  these 
latter  applications  and  lack  of  intelligence  on  his  part,  he 
ceased  to  attend. 

Vague  rumors  of  a  relapse  were  received  later. 

No.  47.  Oncologic  Hospital.  Epithelioma  of  Buccal 
Cavity  and  Cheek. — C.  P.  S.,  aged  y^i'  was  admitted  February 
24,  1905,  with  a  rapidly-growing  cancerous  mass  involving: 
nearly  the  entire  left  cheek  without  and  the  left  side  of  the 
mouth  within,  the  maxilla  being  evidently  involved.  The 
growth  had  appeared  but  six  months  before,  simulating  an 
abscess  of  an  upper  tooth.  Two  teeth  had  been  extracted, 
which  resulted  in  rapidly  increasing  the  growth.  It  has  be- 
come much  larger  during  the  past  two  weeks.  There  was  no 
glandular  involvement.  Microscopic  examination  showed 
squamous-celled  epithelioma. 

On  March  6  a  major  monopolar  application  under  chloro- 
form was  made,  250  to  350  ma,  being  used  for  70  minutes, 
during  5  minutes  of  the  time  the  current  reaching  500  ma. 
(Remark:  The  bipolar  method  would  have  been  more  ef- 
fective.)    Eleven  days  later  there  was  some  bleeding  from  the 


Applications  Within  the  Mouth  and  Nose.  147 

edge  of  devitalized  area,  readily  controlled  by  pledgets  of 
cotton  dipped  in  Monsell's  Solution.  On  the  fourteenth  day 
the  slough  was  lifted  from  the  wound,  revealing  much  disease 
beneath.  During  the  following  three  months  forty-six  minor 
applications  of  15  to  100  ma.  were  made,  ineffectually,  when  he 
was  referred  to  Dr.  Newcomet  for  x-ray  treatment.  This  also 
failed  to  arrest  the  growth,  death  occurring  five  months  later. 

No.  yT,.  Oncologic  Hospital.  Epithelioma  of  Buccal 
Surface  of  Cheek. — W.  M.  D.,  aged  61,  laborer,  w^as  admitted 
March  17,  1905,  with  a  proliferating  growth  on  the  inner  sur- 
face of  the  right  cheek  about  2  inches  in  diameter  and  pro- 
jecting one  inch  from  surface  of  mucous  membrane.  The 
virulence  was  apparently  great,  as  he  stated  that  it  had  been 
first  noticed  but  8  or  9  weeks  before  and  had  grown  rapidly. 
Microscopic  examination  showed  squamous-celled  epithelioma. 
Urinalysis  revealed  evidences  of  chronic  nephritis. 

March  18,  1905.  The  patient  desiring  that  something  be 
done,  in  spite  of  the  condition  of  the  kidneys,  he  was  placed 
under  chloroform  and  200  to  400  ma.  applied  for  one  hour. 

During  the  following  month  11  minor  applications  of  50 
to  100  ma.  were  made  in  an  effort  to  arrest  the  rapid  prolifera- 
tion of  the  growth,  but  the  patient's  general  condition  becoming 
worse,  uremia  appeared,  followed  by  death  April  25. 

No,  183.  Oncologic  Hospital.  Osteosarcoma  of  Lower 
Jaw. — Miss  A.  G.,  aged  14,  was  admitted  from  Tyrone,  Pa., 
July  14,  1905.  Parents  both  alive  and  healthy,  and  family 
history  negative.  Six  months  before  the  growth  was  noticed 
the  girl  fell  against  an  iron  bar,  striking  the  jaw  near  the  site 
of  the  present  growth.  It  was  first  noticed  13  months  ago 
as  a  tumor  of  the  body  of  the  mandible  on  the  left  side,  and 
has  increased  steadily. 

Gondition  on  Admission. — The  patient  is  somewhat  slightly 
built  for  her  age  and  appears  anemic.  The  left  side  of  the 
face  is  greatly  deformed  by  a  protrusion  in  the  region  of  the 
horizontal  body  of  the  mandible.  Examination  within  the 
mouth  shows  a  smooth,  firm  growth  enveloping  the  alveolar 
process  and  about  the  size  of  a  hen's  egg,  one  tooth  having 
fallen  out  and  several  being  raised  from  their  position  and 
pointing  at  various  angles  from  the  tumor,  with  roots  still  ap- 
parently embedded  in  bony  structure. 

Operation. — July  19,  1905.     Though  the  whole  structure  of 


148  Applications  Within  the  Mouth  and  Nose. 

the  jaw  in  this  situation  showed  evidence  of  being  probably 
involved  in  the  growth,  the  desirability  of  avoiding  an  ex- 
ternal scar  and  of  saving  as  much  healthy  tissue  as  possible 
caused  the  decision  to  be  formed  to  destroy  the  growth  by  the 
bipolar  ionic  operation  from  within  the  mouth,  the  large  cur- 
rent necessary  to  destroy  tissue  '  of  the  considerable  cubical 
measurements  involved  in  this  situation  rendering  the  bipolar 
method  desirable  for  other  reasons. 

With  the  patient  anesthetized  with  chloroform,  and- the  lips 
and  tongue  drawn  aside  by  means  of  hard-rubber  retractors,  a 
metallic  negative  electrode  was  inserted  into  the  center  of 
the  growth,  encountering  penetrable  bony  tissue  just  beneath 
the  surface.  Two  somewhat  large,  pointed  zinc-mercury 
electrodes  connected  with  the  positive  pole  were  then  inserted 
at  the  extreme  ends  of  the  growth,  and  a  current  of  500 
milliamperes  was  turned  on.  As  the  tissue  was  whitened  and 
softened  in  the  region  of  each  anode  the  latter  was  removed 
and  inserted  in  a  new  portion  of  the  periphery,  the  current  still 
flowing  through  its  fellow,  until  the  whole  of  the  growth  was 
necrosed,  the  total  time  required  being  50  minutes.  The  sur- 
rounding healthy  structures  were  protected  from  the  action  of 
the  current  by  the  insulation  on  the  electrodes  above  their 
active  surfaces  and  by  the  retractors,  though  with  some  dif- 
ficulty. 

A  specimen  removed  at  the  beginning  of  the  operation  was 
sent  to  the  pathologic  laboratory  and  found  to  be  an  osteosar- 
coma. 

After  History. — The  soft  parts  of  the  slough  showed  the 
usual  white  color  and  emitted  but  slight  odor  during  the 
process  of  separation,  wdiich  was  complete  for  the  soft  parts  in 
ten  days,  exposing  an  irregular,  bony  framework  of  the  same 
shape  as  the  tumor  and  twice  as  wide  as  the  normal  alvec^lar 
process.  This  structure  had  also  been  successfully  devital- 
ized by  the  dispersed  ions. 

The  patient  was  paroled  from  the  hospital  to  the  home  of  a 
relative  in  the  city  at  the  end  of  four  weeks,  with  the  devital- 
ized bone  still  in  place  and  now  requiring  weak  antiseptic 
irrigation  on  account  of  some  odor  and  discharge.  A  small 
external  opening  through  the  cheek  had  also  developed  op- 
posite the  lower  edge  of  the  mandible,  owing  to  the  nearness 
of  the  ionic  action  to  the  skin. 


Applications  Within  the  Month  and  Nose.  149 

September  2,  1905.  Patient  re-admitted  for  the  removal  of 
the  dead  bone  and  destruction  of  some  suspicious  granulations 
about  it.  The  bone  slough  was  but  slightly  attached  to  the 
structure  beneath,  and  when  removed  revealed  the  lower  half 
of  the  body  of  the  mandible  free  from  disease  and  in  good 
condition.  A  monopolar  application  of  345  milliamperes  was 
made  to  the  suspicious  granulations  for  25  minutes,  under 
chloroform. 


Fig.  54. — Case  183  as  outline  of 
lower  jaw  appears  four  years 
after  operation. 

A  month  later  three  minor  applications  were  made  to  sus- 
picious granulations,  without  anesthesia.    < 

The  patient  has  been  seen  or  has  reported  by  letter  at  reg- 
ular intervals  since,  but  no  further  applications  have  been 
required,  the  parts  presenting  a  healthy  appearance,  with  the 
loss  of  four  teeth  and  their  alveolar  process  as  the  only  evi- 
dence of  the  disease  within  the  mouth.  The  external  sinus 
closed  early  with  a  depression  of  the  skin  at  its  site.  The  jaw 
on  this  side  still  shows  some  protrusion,  as  shown  in  the  photo- 
graph (Fig.  54),  though  materially  less  than  before  the 
operation. 

No. 237.      Oncologtc  Hospital.     Probable  RccurrentMyxo- 


150  Applications  Within  the  Month  and  Nose. 

fibrosarcoma  of  Nasal  Cavity. — Mr.  S.,  aged  41,  was  admit- 
ted from  Allentown,  Pa.,  July  22,  1905.  Eight  months  before 
admission  the  patient  consulted  his  family  physician  for  re- 
peated bleeding  from  the  left  nostril.  He  was  treated  from 
that  time  (November,  1904)  until  March,  1905,  by  various 
methods,  a  growth  within  the  nostril  being  finally  recognized 
in  the  latter  month  and  removed  with  the  snare.  The  growth 
recurred  and  was  removed  again  in  May.  In  June  the  growth 
again  recurred  a  second  time  and  was  removed  a  third  time 
with  scissors,  accompanied  by  alarming  hemorrhage. 

Condition  on  Admission. — External  examination  shows  a 
protrusion  on  the  left  side  of  the  nose,  corresponding  in  situ- 
ation with  a  tumor  occluding  the  left  nasal  cavity,  with  a  broad 
attachment  to  the  turbinal.  The  patient  was  in  indifferent 
health  and  complained  of  headaches. 

Operation. — On  July  25,  1905,  the  patient  was  placed  under 
chloroform  and  a  major  monopolar  application  made.  An 
insulated  zinc-mercury  pointed  electrode  of  sufficient  length 
was  inserted  through  the  nostril  into  a  small  incision  in  the 
growth  made  by  scissors  to  secure  a  specimen,  and  a  current 
that  finally  attained  250  milliamperes  was  gradually  turned 
on  and  maintained  for  20  minutes.  The  4iemorrhage  caused 
by  securing  the  specimen  interfered  at  first  with  the  proper 
confinement  of  the  destructive  action  to  the  diseased  part,  but 
within  ten  minutes  all  bleeding  ceased,  and  the  remainder  of 
the  application  permitted  of  such  accurate  control  that  the 
comparatively  strong  current  was  confined  to  the  proper 
structures  and  the  operation  was  completed  without  injury  to 
the  nostrils.  The  anterior  edge  of  the  growth  was  found  to 
begin  one  inch  from  the  external  nostril,  and  it  was  about  an 
inch  in  depth.  In  the  examination  of  the  specimen  removed, 
which  was  small,  and  probably  made  up  of  overlying  mucous 
membrane  alone,  neither  Dr.  McClary  nor  Dr.  Swan  could 
find  certain  evidence  of  malignancy. 

After  Treatment. — The  usual  headache  ^yas  somewhat  ag- 
gravated the  next  day,  but  the  nostril  was  open,  owing  to  the 
retraction  of  the  whitened  necrosis.  The  slough  came  away 
during  the  second  week,  having  been  but  slightly  odorous  under 
weak  permanganate  irrigation,  and  the  patient  was  paroled 
from  the  hospital  under  observation.  Two  months  later  he 
was  re-admitted  for  a  second  major  monopolar  application  to  a 


Applications  Within  the  Mouth  and  Nose.  151 

portion  of  the  growth  that  had  apparently  escaped  the 
first  application,  on  its  posterior  border.  A  current  of  60  ma. 
was  employed  for  15  minutes.  It  was  noted  at  this  time  that 
the  septum  had  been  affected  by  the  first  application,  resulting 
in  the  production  of  a  bone  slough  about  a  centimeter  in 
diameter,  which  came  away  spontaneously  October  15. 

Dr.  G.  Oram  Ring  was  now  called  in  consultation  to  watch 
for  further  recurrences,  and  two  minor  applications  were 
made  to  suspicious  spots  on  January  20  and  February  10,  1906, 
of  4  and  3  ma.  respectively. 

At  the  present  date,  July,  1909,  four  years  after  treatment, 
there  is  no  sign  of  recurrence,  and  the  patient  is  in  excellent 
health.  The  projection  of  the  side  of  the  nose  disappeared 
during  the  first  year  after  treatment. 

No.  206.  Oncologic  Hospital.  Epithelioma  of  Tongue. 
Mrs.  B.  W.,  aged  68,  was  admitted  August  3,  1905,  with  an 
epithelioma  of  dorsum  of  tongue  about  the  size  of  a  half  dol- 
lar and  presenting  a  raised,  ulcerated  surface.  It  had  existed 
nine  months.  The  patient,  whose  intelligence  is  but  slight, 
states  that  a  tumor  was  removed  from  the  mouth  twenty-six 
years  ago.  No  infected  glands  can  be  discovered  in  the  neck 
under  a  careful  examination. 

A  major  monopolar  application  was  made  under  chloroform, 
350  to  400  milliamperes  being  employed  for  30  minutes,  with 
six  needles  inserted  about  the  edges  of  the  growth;  and  one 
month  later  a  minor  application  of  7  milliamperes  to  suspicious 
granulations  completed  the  eradication. 

February  2,  1906.  Examinations  made  on  this  date  showed 
the  tongue  to  be  entirely  free  from  the  disease,  the  scar  being 
healthy  and  inconspicuous.  There  is,  however,  an  enlarged 
gland  in  the  neck  beneath  the  mandible,  evidently  a  pre- 
operative colony.  The  patient  was  advised  to  re-enter  the  hos- 
pital for  operative  removal  of  the  infected  gland,  but  failed 
to  do  so.     No  response  to  letters  of  inquiry  sent  later. 

No.  312.  Oncologic  Hospital.  Epithelioma  of  Tongue. — 
C.  W.  A.,  aged  55,  retired  actor,  was  referred  by  Dr.  Wm. 
Benham  Snow,  of  New  York,  February  15,  1906.  Two  years 
ago  a  white  spot  appeared  on  left  side  of  the  dorsum  of  the 
tongue.  He  was  treated  for  a  time  by  iodides  and  mercury, 
without  effect,  the  spot  becoming  elevated  in  the  center 
and  growing  larger  and  painful.     He  was  given  a  prolonged 


152  Applications  Within  the  Month  and  Nose. 

course   with   the   x-ray   and  high-frequency,    with   temporary 

benefit. 

The  anterior  half  of  the  dorsum  was  the  seat  of  a  leuko- 
plakia! patch,  and  on  this,  somewhat  to  the  left  of  the  center, 
there  is  a  proliferating  tumor  about  the  size  of  a  half- 
dollar,  the  center  being  elevated  about  2  cm.  from  the  sur- 
face. Examination  of  a  specimen  taken  from  the  central 
growth  showed  it  to  be  a  squamous-celled  epithelioma.  No 
enlarged  glands  were  found- 


Fig.     55. — Photograph     of     tongue     scar     as     it       . 
appears    three    and    a    half    A^ears    after    ionic 
destruction  of  epithelioma.     Case  312. 

February  17,  1906.  Major  monopolar  application  under 
chloroform,  300  miUiamperes  being  used  for  30  minutes,  eight 
needles.  The  tongue  was  held  beyond  the  lips  in  the  oper- 
ator's left  hand,  with  a  piece  of  gauze  interposed  to  make  the 
o-rasp  firm,  while  the  right  hand  manipulated  the  needles.  The 
slough  separated  fifteen  days  later,  without  hemorrhage. 
Three  days  later  a  small  minor  application  of  7  ma.  for  15 
minutes  was  made  to  a  doubtful  spot,  two  needles  being  used. 

May  4,  1908.  .  Patient  returns  after  two  years  with  a  doubt- 
ful spot  on  the  tongue  the  size  of  a  split  pea,  the  scar  of  the 


Applications  Within  the  Month  and  Nose.  153 

previous   wound  being-  healthy.     Three   milliamperes    for   20 
minutes,  one  needle. 

June  15,  1908.  Patient  returns  for  photograph  of  tongue 
(Fife-  55)  and  for  additional  minor  treatment  to  spot  near  tip 
of  tongue.  ' 

September  29,  1909.  Patient  shown  at  meeting  of  the 
American  Electro-Therapeutic  Association,  with  excellent  scar 
and  no  sign  of  recurrence. 

No.  475.  Oncologic  Hospital.  Epithelioma  of  Hard 
Palate. — C.  L.,  aged  65,  was  admitted  June  24,  1906,  with  a 
proliferating  growth  projecting  3  cm.  into  mouth  from  the 
hard  palate  to  left  of  median  line,  about  3  cm.  broad  and 
apparently  extending  into  the  bone.  The  growth  had  begun 
several  years  before.  Microscopic  examination  showed  squa- 
mous epithelioma. 

Treatment  was  begun  by  a  major  monopolar  operation  June 
25,  1906,  350  ma.  being  given  for  50  minutes.  When  the 
slough  came  away,  without  hemorrhage,  there  was  an  appar- 
ently healthy  opening  extending  from  the  mouth  into  the 
antrum  one  and  one-half  inches  (4  cm.)  broad,  but  on  the 
roof  of  the  antrum  thus  exposed  there  was  evidence  of 
epitheliomatous  tissue  which  apparently  extended  close  to  the 
floor  of  the  orbit.  He  was  discharged  to  the  dispensary  and 
a  series  of  minor  applications  to  diseased  spot  were  begun, 
averaging  about  20  ma.  for  half-hour  durations,  the  disease 
being  found  later  to  extend  also  into  the  left  temporal  fossa, 
where  an  abscess  ultimately  developed.  He  was  readmitted  to 
the  hospital  December  6,  1906,  and  referred  to  Dr.  Hewson 
for  treatment  of  the  abscess,  and  later  Dr.  Hewson  applied 
chromic  acid  to  the  small  area  of  disease  still  remaining  within 
the  antrum,  the  disease  at  this  time  being  about  a  centimeter 
in  area  only.  This  failed  to  arrest  the  growth,  which  increased 
steadily  and  finally  spread  into  the  abscess  cavity.  During  sev- 
eral months  daily  x-ray  applications  were  made  by  Dr.  New- 
comet. 

July  15,  1907.  The  disease  which  for  a  time  had  been  re- 
duced to  such  small  dimensions,  having  now  invaded  the 
whole  abscess  cavity  reaching  slightly  beyond  the  ear,  and 
having  become  very  painful,  the  patient  was  re-admitted  for 
a  radical  bipolar  ionic  destruction,  the  external  carotid,  lingual 
and  facial  arteries  being  kindly  ligated  at  the  same  opera'tion 


154  Applications  Within  the  Mouth  and  Nose. 

by  Dr.  Despard  immediately  before  the  ionic  destruction. 
The  disease  was  included  in  peripherally  inserted  electrode 
needles,  and,  with  the  negative  placed  on  the  center  exter- 
nally, a  current  of  1200,  decreasing  to  600  milliamperes,  was 
employed  for  30  minutes.  This  resulted  in  destroying  all  ap- 
parent portions  of  the  growth  except  some  near  the  ear;  and 
later  it  was  discovered  that  disease  also  existed  within  the 
orbital  process  of  the  malar  bone  (the  whole  remaining  por- 
tion of  this  bone  and  most  of  the  maxilla  having  disappeared 
and  the  large  cavity  healed  over),  and  an  isolated  area  also 
existed  in  the  nasal  septum.  Between  this  time  and  March  18, 
1908,  the  patient  was  kept  in  the  hospital  and  minor  applica- 
tions made  as  often  as  he  could  stand  them.  On  the  latter 
date  he  was  placed  under  chloroform  and  a  monopolar  ap- 
plication of  100  to  250  ma.  was  made  to  the  worst  areas 
of  disease,  and  on  April  7  and  18  bipolar  applications  were 
made  of  100  to  300  ma. 

Further  treatment  was  abandoned,  at  this  time,  except  such 
as  required  for  the  relief  of  pain  and  weakness,  and  he  died 
January  13,  1909,  of  asthenia  from  the  continued  progress  of 
the  disease. 

No.  429.  Oncologic  Hospital.  Epithelioma  of  Lower 
Jaw. — Mrs.  L.  B.,  aged  65,  was  referred  by  Dr.  J.  E.  McCon- 
nell,  of  Bloomington,  Ind.,  September  15,  1906.  For  sev- 
enteen years  she  had  had  a  growth  on  the  alveolar  process  of 
the  right  posterior  molars  of  the  lower  jaw  which  had  extended 
upwards  to  the  corresponding  wisdom  tooth  of  the  upper  jaw, 
and  recently  to  the  buccal  surface  of  the  cheek.  Dr.  j\IcCon- 
nell  had  employed  the  x-ray  for  six  months.  The  growth  was 
2yi2  inches  (5x5  cm.)  in  diameter  and  ulcerated. 

Treatment  consisted  of  a  major  bipolar  operation  under 
chloroform,  400  to  500  milliamperes  for  15  minutes,  followed 
by  a  monopolar  application  at  the  same  operation  of  300  mil- 
liamperes for  an  additional  15  minutes.  The  slough  separated 
without  hemorrhage  and  leaving  an  apparently  healthy  wound, 
but  with  devitalized  bone  showing  at  the  bottom.  The  patient 
was  returned  to  Dr.  McConnell's  care  during  the  process  of 
separation  of  the  bone,  with  instructions  to  make  minor  ap- 
plications if  necessary,  or,  in  case  of  doubt,  to  send  her  back 
for  further  treatment. 

During  the  separation  of  the  bone,  M^hich  was  necessarily 


Applications  Within  the  Month  and  Nose.  155 

tedious,  a  sinus  opened  through  the  cheek  externally,  appar- 
ently due  to  the  dead  bone,  but  this  was  thought  by  her  at- 
tendants to  be  free  from  disease.  On  learning  of  this  condi- 
tion, and  of  the  slow  separation  of  the  bone,  directions  were 
sent  requesting  the  return  of  the  patient  to  the  hospital  for 
removal  of  the  dead  bone  and  a  further  application  of  the 
ions  to  its  site,  but  other  counsels  were  apparently  followed, 
the  patient  entering  a  hospital  in  Cincinnati  in  September, 
1907,  where  she  was  placed  under  operation  of  some  kind, 
followed  by  paralysis  and  death  some  hours  later.  Whether 
the  epithelioma  had  recurred  or  not  is  unknown. 

No.  446.  Oncologic  Hospital.  Carcinoma  of  Lower  Jaw. 
• — Wm.  McL.,  aged  55,  was  admitted  from  Glassboro,  N.  J., 
October  8,  1906.  He  had  had  a  "sore  mouth  "  for  twenty- 
five  years,  developing  into  a  well-marked  malignant  condition 
about  one  year  before  admission.  Four  months  before  ad- 
mission he  was  admitted  into  a  Philadelphia  hospital,  where  he 
was  given  about  twenty  x-ray  exposures.  Later,  the  surgeon 
in  charge  ligated  the  right  external  carotid  artery  to  cut  off 
nutrition  from  the  growth  and  discharged  him  as  inoperable. 
The  growth  has  increased  greatly  since,  and  now  involves  the 
whole  body  of  the  right  mandible  and  overlying  soft  parts, 
extending  from  the  symphysis  menti  to  the  middle  of  the 
ramus.  Microscopic  examination  by  Dr.  John  M.  Swan 
showed  it  to  be  a  carcinoma. 

The  treatment  of  this  case  extended  over  more  than  two 
and  a  half  years,  or  from  October,  1906,  to  June,  1909,  and 
consisted  of  twelve  major  cataphoric  or  ionic  operations  under 
general  anesthesia  and  a  large  number  of  minor  applications, 
each  operation  failing  to  eradicate  the  disease  effectually  from 
the  cancellous  tissue  of  the  bone  of  the  mandible,  though  keep- 
ing it  under  control.  These  operations  were  mainly  monopolar 
and  of  but  200  to  300  milliamperes,  though  one  was  bipolar 
and  of  600  ma.  for  a  short  duration,  applied  directly  to  the 
structure  of  the  bone.  After  the  second  operation  the  living 
end  of  the  ramus  of  the  jaw  was  effectually  freed  from  the 
disease  and  healed  over  nicely,  with  some  retraction,  but  the 
mental  end  of  the  bone  continued  to  show  disease  until  Janu- 
ary, 1909,  when  a  final  application  to  this  site  destroyed  the 
bone  as  far  back  on  the  left,  or  opposite,  side  of  the  jaw  as 
the  site  of  the  molar  teeth  on  this  side.     The  last  application. 


1^6 


Applications  WitJuii  the  Mouth  and  Nose. 


in  June,  1909,  was  bipolar  and  to  the  edges  of  a  sinus  leading- 
from  the  mouth  externally  just  below  the  site  of  the  chin. 

At  the  present  time  both  ends  of  the  bone  are  healed  over, 
showing  a  loss  of  about  three-quarters  of  the  mandible,  and  the 
floor  of  the  mouth  is  somewhat  contracted,  but  there  is  no 
evidence  of  disease,  and  the  patient  is  in  excellent  health.  The 
deformity  is  not  great,  as  shown  in  the  photograph  (Fig.  56). 

No.  456.  Oncologic  Hospital.  Epithelioma  of  Mouth. — 
T.  M.,  aged  67,  a  stonemason,  was  admitted  from  South  Al- 
lentown,  Pa.,  October  31,  1906.     About  two  years  before  ad- 


FiG.  56. — Amount  of  deformity  after  ionic  destruc- 
tion of  epithelioma  of  lower  jaw,  with  loss  of 
greater  portion  of  mandible.     Case  446. 


mission  he  noticed  a  white  spot  on  the  inner  gum  of  the  lower 
jaw,  next  the  lower  canine  of  the  left  side.  Six  months  ago  he 
entered  the  Hospital  of  the  University  of  Pennsylvania,  where 
the  x-ray  was  advised.  The  growth  has  increased  rapidly  of 
late.  Examination  revealed  a  proliferating  growth  occupying 
the  site  of  the  canine  and  two  bicuspids  and  involving  the 
alveolar  process,  surrounded  by  a  leukoplakial  patch  that  ex- 
tended anjteriorly  and  an  equal  distance  on  the  opposite  side 
of  the  mouth.  Microscopic  examination  showed  it  to  be  a 
squamous  epithelioma. 

A  monopolar  application  under  chloroform  was  made  No- 


Applications  Within  the  Mouth  and  Nose.  157 

vember  i,  1906,  300  to  400  milliamperes  being  used  for  70, 
minutes.  He  was  paroled  from  the  hospital  December  24,  the 
soft  parts  having  separated  nicely,  but  a  bony  slough  being 
still  in  place.  This  came  away  January  23,  1907,  revealing 
some  suspicious  granulations  on  the  surface  of  the  mandible 
to  which  minor  applications  of  10  to  24  ma.  were  made  on 
five  occasions  during  the  following  two  months.  In  Alarch 
there  was  no  evidence  of  the  disease  discernible,  and  the  pa- 
tient was  directed  to  return  for  observation  every  three 
months,  which  he  failed  to  do,  being  ignorant  and  neglectful, 
though  a  letter  was  received  a  year  later  in  respJonse  to  in- 
quiry stating  that  he  was  all  right.  A  neighbor  states  that 
there  is  a  recurrence  in  the  spring  of  1909. 

No.  460.  Oncologic  Hospital.  Epithelioma  of  Mouth. — 
W.  G.  M.,  a  farmer,  aged  73,  was  referred  by  Dr.  Thaddeus 
Irwin  of  Christiana,  Pa.,  November  12,  1906,  with  a  prolifer- 
ating growth  on  the  buccal  surface  of  the  cheek,  extending 
from  the  middle  of  the  cheek  on  the  right  side  around  to  the 
same  point  on  the  left,  in  front  of  the  gums,  the  greatest  ele- 
vation of  the  growth  being  above  the  angle  of  the  mouth  on 
the  right.  In  this  situation  it  was  two  inches  wide  and  one 
inch  thick  (5x2^  cm.).  A  portion  of  the  diseased  tract 
seemed  to  be  simple  leukoplakia,  the  latter  extending  over 
the  external  surface  of  the  lower  lip.  A  brother  died  of 
cancer  of  the  mouth  at  64  years  of  age,  and  a  sister  of  cancer 
of  the  breast  at  59.  The  growth  was  first  noticed  about  two 
years  ago,  and  x-ray  treatment  had  been  ineffectual.  Micro- 
scopic examination  showed  squamous  epithelioma. 

A  major  monopolar  application  was  made  under  ether  No- 
vember 13,  1906,  160  to  200  milliamperes  being  used  for  45 
minutes,  with  several  fine  electrodes,  a  portion  of  the  time  be- 
ing given  to  following  the  leukoplakial  area  with  the  needles. 
The  result  was  excellent  when  separation  occurred,  though  the 
patient  was  kept  under  frequent  inspection,  with  several  minor 
applications  to  suspicious  spots.  By  the  end  of  a  year  a  final 
patch  of  disease  in  front  of  the  sites  of  the  lower  incisors  was 
eradicated  by  a  second  major  monopolar  application,  60  to 
100  ma.  being  used  for  40  minutes. 

November  22,  1909.  Patient  returns  for  regular  inspection, 
showing  no  evidence  of  disease  and  excellent  general  health, 
though  now  past  y6  years.     The  right  angle  of  the  mouth  is 


1=^^ 


Applications  Within  the  Mouth  and  Nose. 


higher  than  the  left  by  reason  of  loss  of  tissue  in  the  right 
buccal  region  (Fig.  57),  the  site  of  the  major  portion  of  the 
growth.     The  scar  tissue  is  soft  and  thin. 

No.  498.  Oncologic  Hospital.  Epithelioma  of  Mouth 
and  Neck,  Recurrent. — W.  H.  C,  aged  63,  civil  engineer,  was 
referred  by  Dr.  Walter  M.  James  of  Philadelphia  January  21, 

1907- 

In  February,  1905,  his  dentist  noticed  a  raised  white  spot 
on  the  side  of  the  gum  of  the  right  jaw,  next  to  the  first 
molar  tooth.     For  a  time  x-ray  treatment  was  employed,  and 


Fig.  57. — Case  460  as  mouth  appears  three  years 
after  destruction  of  epithelioma  of  mucous  mem- 
brane above  right  angle. 


he  was  later  placed  under  operation  in  a  general  hospital  in  the 
city,  the  right  mandible  being  removed  by  excision  from  its 
angle  to  the  symphysis  menti  through  an  external  opening. 
The  wound  never  closed,  recurrence  taking  place  promptly 
over  the  whole  site  of  operation. 

On  admission,  a  large  opening  shows  in  side  of  face  and 
neck  with  proliferating  edges.  Within  the  wound  a  mass  of 
epitheliomatous  new  growth  exists  about  the  size  of  an  orange. 
No  glands  are  apparently  involved.  On  microscopic  exam- 
ination the  growth  was  shown  to  be  a  squamous  epithelioma. 

A  major  bipolar  application  was  made  under  chloroform 
January  22,  1907,  the  negative  being  a  large  oval  electrode 


Applications  Within  the  Mouth  and  Nose.  159 

covered  with  absorbent  cotton  saturated  with  25  per  cent, 
sulphuric  acid  and  water  to  absorb  hydrogen  gas,  etc.^  and 
the  active  ionizing  ones,  zinc-mercury  pointed  electrodes  of 
appropriate  length  inserted  around  the  edges  of  the  growth 
externally,  with  longer,  insulated  ones  inserted  in  the  edges  of 
the  portion  within  the  mouth  through  the  lips.  A  current  of 
1200  to  1600  milliamperes  was  turned  on  and  maintained  for 
an  hour.  Seven  days  later  the  whole  of  the  slough  produced 
came  away,  with  some  hemorrhage  from  a  small  skin  vessel, 
controlled  by  ligature.  On  the  seventeenth  day  a  devitalized 
piece  of  the  mandible  near  the  chin  was  lifted  from  the 
wound,  revealing  considerable  disease  in  the  lower  anterior 
border  of  the  cavity.  This  was  successfully  eradicated  Febru- 
ary 12  by  a  second  major  application  of  240  to  400  milliam- 
peres for  25  minutes,  this  time  monopolar. 

March  14.  Consultation  with  Dr.  Addinell  Hewson,  with 
decision  that  edge  of  wound  nearest  neck  is  healthy.  Some 
disease  shows  in  the  upper  portion  of  the  wound,  in  position 
normally  occupied  by  antrum.  This  was  attacked  later  (May 
14)  by  a  third  major  monopolar  application,  and  the  patient 
was  then  directed  to  return  for  minor  applications,  of  which 
52  were  given  during  May  and  June.  These  minor  applica- 
tions were  of  10  to  15  milliamperes,  but  were  quite  painful 
as  the  diseased  spot  was  no  larger  than  a  dime,  though  situ- 
ated immediately  under  the  floor  of  the  orbit.  Following  the 
separation  of  the  slough  of  one  of  these  minor  applications  the 
patient  had  two  severe  hemorrhages  from  the  infraorbital 
artery,  expiring  during  the  second  hemorrhage. 

No.  514.  Oncologic  Hospital.  Epithelioma  of  Mouth. — 
G.  K.,  farmer,  aged  53,  was  admitted  from  Villisca,  Iowa, 
February  12,  1907.  For  a  number  of  years  he  had  had  a 
leukoplakial  patch  in  the  sulcus  between  the  left  cheek  and  the 
teeth  of  the  lower  jaw.  Six  months  ago  a  growth  appeared 
in  the  center  of  the  patch  and  has  increased  rapidly  since,  giv- 
ing rise  to  soreness  and  frequent  lancinating  pains.  Examina- 
tion shows  a  white,  proliferating  growth  in  the  sulcus,  ex- 
tending from  the  first  incisor  tooth  to  the  intermaxillary  com- 
missure and  from  the  margin  of  the  gums  up  on  the  cheek. 
Beyond  the  commissure  the  growth  extended  up  on  the  mucous 
membrane  of  the  hard  palate  about  3  cm.  Further  examina- 
tion   showed   that   the   patient   was    suffering    from   incipient 


i6o  Applications  Within  the  Month  and  Nose. 

Bright's  disease,  rendering  a  major  application  inadvisable. 
Microscopic  examination  showed  squamous  epithelioma. 

It  being  decided  to  destroy  as  much  of  the  growth  as  pos- 
sible by  the  minor  method,  he  received,  between  the  date  of 
admission  and  September  13,  one  hundred  and  thirteen  minor 
applications,  varying  from  30  ma.  for  one  hour  to  3  ma. 
for  half  an  hour,  the  later  applications  being  the  weaker  ones 
as  the  growth  was  destroyed.  At  this  time  (September  13, 
1907),  he  was  sent  home  without  manifest  evidence  of  disease, 
healthy  mucous  membrane  having  covered  the  site  of  growth, 
but  with  the  injunction  to  return  for  further  treatment  if 
suspicious  granulations  appeared. 

In  a  letter  dated  December  14,  1907,  the  patient  reports  a 
slight  evidence  of  possible  disease,  but  has  so  far  failed  to 
return. 

No.  540.  OxcoLOGic  Hospital.  Carcinoma  of  the  Mouth 
and  of  the  Sublingual  and  Submaxillary  Glands,  both  Sides 
of  Neck. — Sig.  C.  A.,  sugar  planter,  aged  56,  was  referred 
by  Dr.  C.  ^l.  Desvernine,  of  Havana,  Cuba,  April  15, 
1907. 

A  little  over  a  year  ago  a  tumor  was  noticed  in  the  floor  of 
the  mouth  beneath  the  tongue,  which  later  ulcerated  and  in- 
creased rapidly  in  size,  with  severe  lancinating  pain.  Ex- 
amination on  admission  showed  an  excavation  occupying  the 
whole  anterior  floor  of  the  mouth  and  under  side  of  the  tip 
of  the  tongue,  with  raised  and  indurated  edges.  The  sub- 
maxillary and  sublingual  glands  of  both  sides  were  enlarged 
to  the  size  of  chestnuts.  The  general  health  was  good,  ex- 
cept for  the  presence  of  considerable  albumen  and  a  few 
casts  in  the  urine. 

With  a  view  to  a  thorough  ionic  destruction  of  the  cancer- 
ous area  and  glands  Dr.  Hewson  was  asked  to  ligate  both  ex- 
ternal carotids,  which  was  done  successfully  in  two  operations 
on  the  25th  and  30th  of  April,  in  spite  of  the  condition  of  the 
kidneys,  for  which  the  patient  had  been  placed  under  appro- 
priate treatment.  At  these  operations  the  glands  were  also  re- 
moved by  excision,  contrary  to  ni}'  original  intention,  and 
the  prompt  recifrrence  of  the  disease  in  a  diffused  form  on 
the  left  side  of  the  neck  in  the  interval  of  delayed  ionic  de- 
struction at  this  site  was  possibly  the  chief  cause  of  ultimate 
failure  to  eradicate  the  disease.     ^Microscopic  examination  of 


Applications  Within  the  Mouth  and  Nose.  i6i 

both  the  primary  growth   and   removed  glands   showed   car- 
cinoma.. 

The  removal  of  the  glands  being  for  a  time  apparently  suc- 
cessful, the  major  bipolar  ionic  operation  was  proceeded  with 
May  i6,  but  confined  to  the  growth  in  the  mouth  alone.  Five 
hundred  to  600  milliamperes  w^ere  employed  for  30  minutes, 
the  negative  electrode  being  placed  in  the  center  of  the  excava- 
tion and  the  active  needles  in  turn  around  the  periphery,  pierc- 
ing the  tongue  and  floor  of  the  mouth  slightly  beyond  the  dis- 
ease. The  separation  of  the  slough  was  uneventful,  but  re- 
vealed doubtful  tissue  at  the  bottom  of  the  cavity. 

•  On  August  6  the  site  of  the  excised  glands  on  the  left  side 
of  the  neck  showing  a  diffused,  increasing  grow^th,  a  major 
bipolar  application  was  made,  the  tissue  being  transfixed  by  a 
curved  needle  with  a  stout  ligature,  traction  on  the  latter  en- 
abling much  of  the  growth  to  be  drawn  away  from  the  under- 
lying vessels.  The  negative  electrode  v/as  placed  over  the 
center  and  the  active  electrodes  transfixed  the  growth  near  its 
base.  A  current  of  300  to  700  ma.  was  used  for  10  minutes. 
At  the  same  operation  a  monopolar  application  of  300  milli- 
amperes for  20  minutes  was  made  to  the  remnant  of  disease 
within  the  mouth.  On  the  i6th,  during  the  separation  of  the 
mouth  slough,  a  slight  hemorrhage  occurred  beneath  the 
tongue,  controlled  by  cotton  pledgets  saturated  with  Mon- 
sell's  Solution,  followed  by  a  severe  one  on  the  19th  and 
another  on  the  24th,  both  controlled  with  difficulty  by 
packing. 

On  the  removal  of  the  packing  no  disease  was  revealed 
within  the  mouth,  but  there  were  evidences  of  abnormal  tissue 
between  the  outer  and  inner  sites  of  application  and  beneath 
the  outer  site,  which  were  attacked  by  a  third  major  applica- 
tion on  October  2,  of  200  to  700  ma.,  bipolar,  and  450 
monopolar,  for  30  minutes  each,  resulting  in  eradicating  the 
disease  between  the  mouth  and  neck  situations,  but  not  in  the 
latter,  to  which  site  repeated  minor  applications  were  made 
and,  on  November  4,  a  fourth  major  application  of  300  milli- 
amperes for  45  minutes,  monopolar. 

On  the  30th  of  December  a  piece  of  devitalized  mandible,  5 
cm.  long,  was  lifted  from  the  wound,  and  it  was  noted  that 
the  parts  within  the  mouth  remained  healthy  and  that  the  pa- 
tient's weight  had  greatly  increased,  but  that  the  site  of  the  re- 


i62  Applications  IVitliin  the  Mouth  and  Nose. 

currence  in  the  left  side  of  the  neck  was  doubtful,  and  minor 
applications  were  resumed. 

February  ii,  1908.  The  disease  still  existing  beneath  the 
site  of  the  left  submaxillary  gland  removed  in  the  knife 
operation,  a  fifth  major  application  was  attempted  for  its 
eradication,  the  disease  being  deeply  situated  in  the  neck.  The 
patient  bore  the  ether  very  badly,  becoming  repeatedly  cyanotic. 
From  200  to  400  milliamperes  were  attained,  bipolar,  but 
cyanosis  becoming  greater  the  current  was  reduced  to  100  after 
15  minutes.  The  operation  was  begun  at  4.10  P.  M. ;  at  4.30 
breathing  ceased,  and  the  patient  expired  in  spite  of  efforts  at 
artificial  respiration,  intravenous  salt  solution,  and  other 
restoratives. 

No.  548.  Oncologic  Hospital.  Probable  Epithelioma, 
Associated  zuith  Leukoplakia,  of  Mouth. — Mr.  F.,  aged  61,  a 
merchant,  was  referred  by  Dr.  Park  Brenneman,  of  Lancaster, 
Pa.,  April  27,  1907.  For  three  years  he  has  had  a  white  patch 
of  leukoplakia  on  the  buccal  surface  of  the  cheeks,  extending 
over  the  whole  of  the  anterior  surface  of  the  mouth  outside 
the  teeth.  It  has  grown  steadily  worse  in  spite  of  the  removal 
of  all  of  his  teeth,  the  bad  condition  of  which  was  thought 
to  have  produced  or  added  to  the  trouble.  In  the  sulcus  be- 
tween the  gums  and  cheek  the  growth  resembles  epithelioma, 
but  the  microscopic  examination  was  negative. 

May  2,  1907.  Major  monopolar  application  under  chloro- 
form. The  area  was  attacked  at  one  end  with  five  fine,  zinc- 
mercury  points  and  a  current  of  160  to  200  milliamperes,  the 
needles  being  moved  from  time  to  time  until  the  whole  of  the 
diseased  area  was  progressively  brought  under  the  influence  of 
the  radiated  ions,  the  lips  and  tongue  being  meantime  pro- 
tected by  hard-rubber  retractors  and  the  partial  insulation  of 
the  needles.  Since  the  part  to  be  destroyed  was  broad  and 
thin,  the  problem  of  restricting  the  ionization  to  diseased  tissue 
alone  was  met  by  inserting  the  needles  parallel  to  the  surface 
of  the  growth  and  not  perpendicular,  as  usually  done.  The 
operation  was  completed  in  25  minutes.  The  slough  cleared 
off  nicely  by  the  end  of  the  second  week,  when  he  was  dis- 
charged to  the  dispensary  for  observation,  minor  applications 
of  5  to  12  ma.  being  needed  on  four  occasions  during  the  fol- 
lowing month. 

May    25,    1909.     Examination    to-day    shows    smooth    and 


Applications  Within  the  Mouth  and  Nose.  163 

healthy  membrane  covering  former  site  of  disease,  and  no  evi- 
dence of  recurrence. 

No.  569.  Oncologic  Hospital.  Recurrent  Epithelioma  of 
Tongue. — Sig.  M.,  aged  51,  sugar  planter,  was  referred  by 
Dr.  Desvernine  of  Havana,  Cuba,  June  11,  1907.  For  four 
or  five  years  he  had  had  a  patch  of  leukoplakia  on  the  dorsum 
of  the  tongue.  In  August,  1906,  it  ulcerated  and  grew  more 
rapidly.  In  February  of  the  present  year,  after  the  question 
of  specific  disease  had  been  settled  in  the  negative,  the  growth 
was  removed  by  excision,  with  the  whole  dorsum  of  the 
tongue,  by  a  surgeon  in  Havana,  who  at  the  same  time  ligated 
both  lingual  arteries.  By  May  18  he  noticed  a  recurrence  of 
both  the  growth  and  pain,  and  they  are  now  increasing  rapidly. 
For  six  days  he  has  been  restricted  to  a  milk  diet. 

Examination. — Patient  is  anemic,  but  not  surely  cachectic. 
The  scar  and  surrounding  portion  of  remnant  of  tongue  are 
covered  with  proliferating  elevations  and  ulcerations.  A  care- 
ful examination  of  the  neck,  kindly  made  by  Dr.  Newcomet^ 
failed  to  reveal  enlarged  glands  at  this  time.  Blood  count: 
5,600  white,  5,000,000  red,  arid  hemoglobin  83  per  cent.  The 
microscopic  examination  was  apparently  in  the  negative  as  to 
malignancy,  but  clinical  evidences  and  the  final  termination  of 
the  case  removed  all  doubt. 

June  13,  1907.  A  major  monopolar  application  under 
chloroform  was  made,  500  to  600  milliamperes  being  used  for 
25  minutes  to  the  affected  surfaces,  effectually  destroying  all 
proliferating  tissue,  with  its  base.  The  slough  came  away  on 
the  twelfth  day,  accompanied  by  sufficient  hemorrhage  to  re- 
quire packing  with  Monsell's  Solution. 

July  23.  An  enlarged  gland  in  the  neck  has  been  lately  ap- 
parent, situated  immediately  over  the  bifurcation  of  the 
carotid.  This  was  kindly  removed  to-day  by  Dr.  Despard,  by 
excision.  A  month  later  a  minor  application  of  3  milliamperes 
for  20  minutes  was  made  to  doubtful  granulations  on  the 
tongue  and  the  patient  was  sent  home,  without  manifest  evi- 
dence of  disease. 

February  26,  1908.  Letter  received  from  Dr.  Desvernine 
announcing  death  of  the  patient  from  recurrence  of  the  disease 
in  the  neck.  There  was  no  return  of  the  primary  growth  on 
the  tongue. 

No.  574.    Oncologic  Hospital.    Carcinoma  of  the  Tongue. 


164  Applications  Within  the  Mouth  and  Nose. 

— Mrs.  L.,  aged  2>^,  was  referred  by  Dr.  W.  S.  Newcomet  June 
18,  1907.  Five  years  before  the  patient  had  noticed  a  small 
"  white  spot "  on  the  left  side  of  the  dorsum  of  the  tongue. 
One  and  a  half  years  ago  it  began  to  give  rise  to  a  burning 
sensation  and  increase  in  size.  Dr.  Newcomet  had  used  the 
x-ray  during  the  past  winter  and  spring  with  some  effect,  and 
had  also  cauterized  it. 

Examination  showed  a  raised,  ulcerated,  proliferating 
growth  on  the  dorsal  surface  of  the  tongue  near  the  middle 
of  the  left  edge,  about  4  cm.  long,  2  wide,  and  protruding  2 
cm.  above  the  surface  of  the  tongue.  The  induration  be- 
neath it  extended  through  the  tongue  to  the  floor  of  the  mouth. 
There  is  a  movable  gland  distinctly  palpable  below  the  man- 
dible, but  Dr.  N.  thought  it  due  to  the  treatment,  as  it  had 
varied  in  size. 

June  20,  1907.  Major  monopolar  application  under  chloro- 
form, 300  to  360  milliamperes  for  40  minutes.  Four  electrodes 
were  inserted  in  the  periphery  of  the  growth  and  thrust  down 
through  the  tongue  towards  the  floor  of  the  mouth.  On  the 
sixteenth  day  the  devitalized  tissue,  measuring  5  by  2^^  cm., 
was  lifted  bloodlessly  from  a  cavity  that  extended  below  the 
level  of  the  floor  of  the  mouth,  and  on  July  10  she  was  dis- 
charged from  the  hospital  in  excellent  condition  as  to  the 
wound,  but  with  a  doubtful  area  in  front  of  it,  in  the  floor  of 
the  mouth.  During  the  next  two  months  this  area  was  gradu- 
ally destroyed  by  twelve  minor  applications  of  5  to  12  milliam- 
peres for  a  half-hour  each,  and  by  October  10  it  w^as  noted 
that  the  mouth  was  free  from  the  disease,  with  a  scar  in  the 
tongue  that  interferes  very  little  with  articulation. 

March  19,  1909.  Patient  visited  hospital,  showing  no  evi- 
dence of  the  disease  within  or  without  the  mouth.  The  en- 
larged gland  below  the  angle  of  the  jaw  is  smaller,  and  on 
diligent  examination  a  similar  palpable  gland  is  found  on 
the  opposite  side  of  the  neck,  both  probably  due  to  old  tuber- 
cular deposits. 

No.  576.  Oncologic  Hospital. — Carcinoma  of  Tongue 
and  Neck. — J.  McD.,  aged  64,  was  referred  by  Dr.  Bruce 
Richards,  of  Philadelphia,  June  20,  1907.  Of  negative  per- 
sonal and  family  history  and  excellent  physique,  he  had  bitten 
his  tongue  six  weeks  before,  resulting  in  a  sore  in  the  right 
^dge  of  the  latter,  which  he  thought  had  been  made  worse  by 


Applications  Within  the  Month  and  Nose.  165 

the  sharp  edge  of  a  tooth.  This  was  filed  down  by  a  dentist 
four  weeks  ago,  but  the  sore  not  only  failed  to  heal,  but  grew 
rapidly  worse,  and  a  tumor  appeared  below  the  ear,  in  the 
neck.  The  opposite  parotid  gland  is  evidently  enlarged. 
Pathologic  report^  on  specimen  removed  at  subsequent  opera- 
tion :  Not  malignant;  possibly  a  gumma  (  ?). 

June  21.  Alajor  bipolar  operation  under  chloroform,  500 
to  600  milliamperes  for  30  minutes  to  growth  on  tongue.  The 
growth  on  the  neck  w*as  not  touched  on  account  of  its  deep 
situation  among  the  neck  structures,  and  also  in  view  of  the 
possibility  of  its  being  the  seat  of  a  benign  inflammation  like 
the  parotid  gland  on  the  opposite  side.  The  devitalized  tissue 
separated  from  the  tongue  on  the  eighth  day,  without  hemor- 
rhage, leaving  a  healthy  wound ;  and  the  swelling  in  the  parotid 
gland  on  the  opposite  side  of  the  neck,  after  increasing  im- 
mediately subsequent  to  the  operation,  later  disappeared.  The 
neck  tumor  on  the  affected,  right,  side  nevertheless  continued 
to  grow  steadily,  and  the  patient  was  referred  to  the  x-ray  de- 
partment, with  the  tongue  showing  no  evidence  of  the  disease. 

Word  was  received  of  the  patient's  death  subsequently  at 
his  home,  from  continued  growth  of  the  neck  carcinoma. 

No.  830.  Oncologic  Hospital.  Epithelioma  of  Mouth 
and  Neck.—C.  S.  H.,  aged  50,  applied  for  treatment  July  8, 
1907.  Eighteen  months  before  he  had  noticed  a  rough  place 
on  the  inner  side  of  the  gum  and  floor  of  the  mouth,  next  the 
lower  molar  teeth  of  the  left  side.  A  year  later  the  growth 
increasing  steadily  he  consulted  a  surgeon,  who  advised  re- 
moval of  the  jaw.  The  growth  was  examined  at  this  time  in 
the  laboratories  of  the  University  of  Pennsylvania  and  pro- 
nounced a  squamous-cell  carcinoma. 

On  examination,  an  area  of  proliferation  was  found  on  both 
sides  of  the  lower  molar  teeth  and  floor  of  the  mouth,  ex- 
tending on  the  latter  forward  nearly  to  the  symphysis  menti. 
No  enlarged  glands  could  be  found  at  this  time. 

The  patient  was  greatly  opposed  to  an  anesthetic,  and  as  the 
growth  appeared  to  be  rather  superficial,  though  covering  a 
considerable  area,  it  was  decided  to  attempt  its  destruction 
by  repeated  minor  applications  in  the  office.  These  were  ac- 
cordingly begun,  a  single  slender  electrode,  properly  insulated 
and  curved,  being  employed  at  each  treatment.  The  current 
strength  was  at  first  10  and  15  milliamperes,  but  later  from  5 


i66 


Applications  Within  the  Moutli  and  Nose. 


to  10  only  could  be  borne,  the  duration  being  in  each  case 
30  minutes.  The  treatment  covered  a  year  in  time,  during 
which  fifty  applications  were  made,  at  increasing  intervals 
as  the  parts  improved.  Three  months  later  he  was  exam- 
ined and  a  palpable  gland,  enlarged  to  the  size  of  a  chestnut, 
was  found  beneath  the  angle  of  the  jaw,  and  a  remnant  of  the 
primary  growth  still  existed  in  the  socket  of  the  bicuspid 
tooth.     A  through-and-through  ionic  destruction  was  advised. 


Fig.  58. — Case  830  after  separation  of  slough,  showing  cavity 
from  which  devitaUzed  gland  has  been  removed,  sixteen  days 
after  operation. 


October  16,  1908.  Patient  admitted  to  Oncologic  Hospital 
and  major  bipolar  application  of  500  to  650  milliamperes  was 
made  for  20  minutes,  with  the  negative  on  the  skin  over  the 
gland  just  back  of  the  facial  artery,  and  four  insulated  needles 
inserted  internally  through  the  floor  of  the  mouth  into  the  af- 
fected gland,  two  on  each  side  of  the  mandible.  The  needles 
were  then  transferred  to  the  periphery  of  the  gland  externally 
and  a  monopolar  application  of  100  to  200  ma.  was  made  for  30 
minutes.     The  area  of  skin  and  subdermic  tissues  destroyed 


Applications  Within  the  Mouth  and  Nose. 


i6j 


measured  5  cm.  in  diameter.  At  the  completion  of  the  opera- 
tion the  tooth  that  had  been  surrounded  by  the  disease  was 
drawn  bloodlessly. 

October  23.  The  patient's  face  and  neck  are  greatly  swol- 
len, but  there  is  no  pain.  The  pulsations  of  the  temporal 
artery  can  be  detected  to-day. 

November  2.  Devitalized  tissue  removed  to-day,  showing 
cavity  5  cm.  wide,  with  devitalized  bone  at  the  bottom,  below 


FiG-  59. — Case  830,  showing  appearance  of  scar  one  year 
after  ionic  operation  for  epithelioma  of  neck  gland. 


which  an  opening  into  the  mouth  exists  (Fig.  58).  The 
devitalized  gland  resembles  punk,  and  was  readily  separated 
from  the  remainder  of  the  ionized  tissue. 

December  5.  Patient  discharged  from  hospital,  to  report 
daily  for  dressing  and  irrigation.  The  external  wound  has 
contracted  to  one-half  its  size.  There  is  much  swelling  of  the 
face  above  the  wound. 

April  13,  1909.  Greater  portion  of  the  devitalized  body  of 
the  left  mandible  found  loose  and  extracted  from  wound  inside 
mouth  by  a  pair  of  forceps. 

July  23.     Eight  minor  applications  of  5  to  10  ma.  have  been 


i68  Applications  Within  the  Month  and  Nose. 

made  to  suspicious  tissue  back  of  canine  and  incisor  teeth,  and 
the  teeth  extracted. 

November  8,  1909.  Patient  reports  at  hospital  with  good 
scar,  and  no  evidence  of  recurrence.  The  external  conditions 
are  shown  in  the  photograph  (Fig.  59). 

No.  597.  Oncologic  Hospital.  Carcinoma  of  Mouth  and 
Neck,  Virulent  Type. — F.  McF.,  an  iron  molder,  aged  63,  was 
referred  by  Dr.  F.  E.  Archibald  of  Philadelphia  August  13, 
1907.  Six  months  ago  the  patient  noticed  for  the  first  time 
a  movable  lump  in  the  side  of  the  neck  about  the  size  of  a  lima 
bean,  but  did  not  discover  the  apparently  primary  growth  in 
the  buccal  surface  of  the  cheek,  opposite  middle  molar  tooth, 
until  six  weeks  ago.  One  week  after  noticing  lump  within  the 
mouth  (five  weeks  ago)  he  had  the  tooth  nearest  the  growth 
extracted,  resulting  in  a  rapid  augmentation  of  the  growth. 

On  admission,  there  is  a  large,  proliferant  and  ulcerated 
growth  in  the  right  side  of  the  mouth,  involving  both  gum  and 
cheek,  including  the  whole  thickness  of  the  latter,  and  a  large, 
immovable  tumor  externally  below  the  angle  of  the  jaw. 
Pathologist's  report :  squamous  epithelioma. 

August  21.  The  external  carotid  artery  of  the  affected  side 
was  ligated  by  Dr.  McClary  in  preparation  for  the  ionization 
operation,  and  on  the  30th  this  was  proceeded  with,  iioo  to 
1200  milliamperes  being  employed,  bipolar,  for  45  minutes.  On 
the  separation  of  the  dead  tissue  a  local  failure  to  eradicate 
was  evident,  and  a  second  major  bipolar  application  was  made 
September  13,  1000  ma.  being  used  for  16  minutes.  This  was 
repeated  September  24,  followed  by  14  minor  applications. 
On  October  30  a  large  portion  of  the  devitalized  mandible 
came  away,  revealing  much  disease  in  neck  and  face,  and 
further  treatment  of  an  active  nature  was  abandoned.  De- 
cember 9  there  was  a  severe  spontaneous  hemorrhage  from 
the  diseased  area,  which  had  grown  much  worse,  and  on  the 
20th  he  died  of  repeated  losses  of  blood  from  local  extension 
of  the  disease. 

No.  652.  Oncologic  Hospital.  Epithelioma  of  Mouth. — 
E.  D.,  a  farmer,  aged  80,  was  referred  by  Dr.  J.  C.  McClure 
of  Williamstown,  N.  J.,  November  23,  1907.  Seven  months 
before  admission  the  patient  noticed  a  growth  projecting  from 
the  buccal  surface  of  the  right  cheek.  In  August  it  became 
painful. 


Applications  Within  the  Mouth  and  Nose.  169 

Examination  on  admission  shows  a  growth  just  within  the 
right  angle  of  the  mouth  on  the  buccal  mucous  membrane  about 
the  size  of  a  silver  dollar  and  3  cm.  thick,  extending  from  the 
margin  of  the  gum  and  angle  of  mouth  upward.  The  surface 
showed  proliferation  and  ulceration.  Pathologic  report : 
Epithelioma. 

November  12,  1907.  Monopolar  operation  under  chloro- 
form, 200  to  300  milliamperes  for  50  minutes,  with  six 
needles.  The  devitalized  tissue  separated  bloodlessly  on  the 
fourteenth  day,  showing  a  healthy  wound,  and  the  patient  was 
discharged,  without  manifest  evidence  of  disease,  January  22, 
1908. 

November  15,  1909.  No  disease  found  on  examination. 
The  site  of  the  wound  is  covered  with  a  soft,  pink  cicatrix 
which  limits  to  some  extent  the  separation  of  the  jaws. 

No.  697.  Oncologic  Hospital.  Epithelioma  of  Month 
with  Horny  Growth  of  Lip. — E.  M.,  aged  68,  was  referred  by 
Dr.  Lambert  Ott  of  Philadelphia,  ]\Iarch  16,  1908.  Four  years 
before  a  growth  appeared,  the  size  of  a  pea,  on  the  buccal 
mucous  membrane  opposite  the  first  lower  molar  tooth  on  the 
left  side.  It  increased  slowly  and  spread  to  the  left  corner  of 
the  mouth,  finally  penetrating  the  cheek  and  appearing  ex- 
ternally. A  caustic  paste  was  ineffectually  used  in  July,  1907, 
and  Dr.  Ott  later  used  the  x-ray  for  a  time. 

On  the  upper  lip  near  the  angle  of  the  mouth  there  are  two 
large  horns,  2  cm.  in  length  by  7  mm.  in  breadth,  with  blunt 
tips,  corneous  in  texture  and  yellowish  in  color  (Fig.  60).  Be- 
neath this  the  greater  part  of  the  upper  lip  is  thickened,  in- 
durated and  covered  with  crusts.  AVithin  the  mouth,  on  the 
buccal  aspect  of  the  cheek,  there  is  a  large  fungoid  mass  4  by  5 
cm.  broad  and  involving  the  whole  thickness  of  the  cheek. 
Microscopic  examination :  squamous  epithelioma. 

March  18,  1908.  Major  application  under  chloroform,  300 
to  400  milliamperes,  bipolar,  for  13  minutes,  negative  ex- 
ternally, followed  by  300  milliamperes  monopolar  for  an  addi- 
tional 25  minutes.  The  horns  dropped  off  on  the  removal 
of  the  dressing  the  following  day,  and  the  remainder  of  the 
devitalized  tissue  on  the  seventeenth  day.  During  the  next 
two  months  eight  minor  applications  were  made  to  doubtful 
granulations,  of  3  to  11  milliamperes.  On  October  19  and 
November  30  he  visited  the  hospital  with  a  well  healed  scar 


170 


Applications  IVithin  the  Mouth  and  Nose. 


that  was  thought  to  be  thicker  than  normal,  but,  under  con- 
sultation, a  waiting  policy  was  followed. 

October  17,  1909.  Patient  visits  hospital  with  a  healthy- 
scar  that,  by  its  normal  contraction,  has  restored  the  normal 
angle  to  the  mouth  (Fig.  61).  The  scar  is  softer  and  thinner 
than  a  year  before,  pink  in  color,  and  shows  no  sign  of  recur- 
rence. 

No.  769.  Oncologic  Hospital.  Epithelioma  of  Tongue 
and  Neck. — E.  N.,  aged  52,  was  referred  by  Drs.  Newcomet 
and  Blackburn  of  Philadelphia,  June  10,  1908.     For  ten  years 


Fig.  60. — Case  697.     Horny  growth  on  lip,  with 
epithelioma  of  mouth. 


he  had  had  a  leukoplakial  patch  on  the  dorsum  of  the  tongue  to 
left  of  the  median  line.  Five  months  ago  he  lifted  a  crust 
from  its  center  and  noticed  an  ulceration  beneath.  The  tumor 
has  grown  rapidly  since,  and  he  suffers  from  paroxysms  of 
pain  extending  to  whole  of  left  side  of  head  about  every  three 
hours. 

Examination  showed  a  raised,  indurated,  proliferating 
growth  occupying  about  one-third  of  the  dorsum  of  the  tongue, 
extending  from  the  extreme  left  border  to  near  the  right 
border,  and  of  equal  antero-posterior  diameter;  ulcerated  in 


Applications  Within  the  Mouth  and  Nose.  171 

the  center  and  with  raised  edges.  In  the  left  side  of  the 
neck  there  are  one  or  more  palpable  glands  the  size  of  a  pea. 
His  appearance  was  cachectic.  Microscopic  examination: 
cylindric-cell  epithelioma. 

June  12,  1908.  Major  bipolar  destruction  of  the  tongue 
growth  under  chloroform,  600  to  1000  milliamperes  for  30 
minutes.  A  silk  thread  was  then  passed  through  the  skin  be- 
neath the  enlarged  glands  in  the  neck,  they  were  raised,  zinc- 
mercury  needles  passed  beneath,  and  with  the  negative  on  the 
skin  over  the  glands,  the  mass  was  destroyed  by  800  to  1000 


■^fWHIiiiiJBMi 


^i^S^i^m 


Fig.  61. — Case  697.  Appearance  of  scar  one 
3nd  a  half  years  after  destruction  of 
epithelioma  of  mouth  and  lip. 

milliamperes  for  10  minutes.  On  the  separation  of  the  de- 
vitalized tissue,  which  was  accompanied  by  a  sharp  hemor- 
rhage, a  local  failure  to  eradicate  the  growth  from  the  edges 
of  the  wound  in  the  tongue  was  noted,  and  later  a  second  en- 
larged gland  was  evident  in  the  edge  of  the  neck  wound. 

August  12.  Readmitted  with  elevated  and  indurated  edges 
surrounding  the  tongue  wound,  an  enlarged  gland  alongside 
the  scar  in  the  neck,  and  a  similar  one  on  the  opposite  side  of 
the  neck.  There  has  been  no  return  of  the  neuralgic  pains. 
Second  major  bipolar  application  to  each  gland  of  800  to  looo 
ma.  for  a  total  duration  of  16  minutes,  followed  by  a  monopolar 


172  Applications  Within  the  Mouth  and  Nose. 

to  the  tongue  of  50  ma.  for  30  minutes.     On  separation  of  the 
devitahzed  tissue  disease  was  still  evident  in  each  situation. 

August  31.  Third  major  bipolar  application,  500  to  800  ma. 
for  45  minutes  to  tongue,  and  250  to  300,  monopolar,  to  neck. 

September  14.  Fourth  major  bipolar  application  to  tongue 
and  neck,  600  to  800  ma.  for  45  minutes. 

October  5.  Fifth  major  bipolar  application,  200  to  600  ma. 
for  25  minutes. 

November  10.  Patient  referred  to  the  care  of  Drs.  New- 
comet  and  Codman  of  the  staff  as  an  ionization  failure,  the 
severe  pains  having  returned  with  the  local  recurrence  of  the 
growth.     Daily  applications  of  the  x-ray  begun. 

December  3.  The  x-ray  treatment  is  discontinued  and  pa- 
tient placed  on  supporting  treatment  alone  and  for  alleviation 
of  the  symptoms  of  the  rapidly  increasing  growth,  the  three 
sites  having  now  coalesced  into  a  common  proliferation.  Death 
occurred  December  "22. 

No.  926.  Oncologic  Hospital.  Carcinoma  of  Fauces  and 
Neck. — Judge ,  aged  50,  was  referred  by  Dr.  C.  A.  Don- 
aldson of  Minneapolis,  Minn.,  April  15,  1909.  A  fissure  was 
first  noticed  on  the  anterior  pillar  of  the  fauces,  right  side,  in 
October,  1908,  and  during  the  following  month  an  enlarged 
gland  in  the  neck.  In  December  he  was  placed  on  the  x-ray, 
both  internally  and  externally,  which  has  been  continued  al- 
most daily  to  the  present  time.  Since  midwinter  there  has 
been  a  neuralgic  pain  in  the  distribution  of  the  fifth  nerve. 

Examination. — The  jaws  can  be  separated  2  cm.  only.  On 
looking  within  the  mouth  an  excavation  is  seen  on  the  anterior 
pillar  of  the  right  fauces  2  cm.  long,  extending  to  hard  palate, 
with  punched-out  edges  and  surrounded  by  indurated  tissue- 
On  the  outside  of  the  neck  there  is  a  raised,  hard  tumor  be- 
neath the  unbroken  skin  immediately  below  the  right  ear  and 
extending  to  the  angle  of  the  jaw.  It  is  immovable,  and  evi- 
dently penetrates  deeply  into  the  neck,  completing  an  un- 
broken area  of  disease  extending  from  immediately  below  the 
skin  to  the  pharynx.     Microscopic  examination :  carcinoma. 

April  17.  Decision  having  been  arrived  at  to  give  the  pa- 
tient the  slight  chance  of  a  through-and-thrbugh  ionic  destruc- 
tion being  successful,  and  trusting  to  pressure  as  a  hemostatic 
if  necessary  for  secondary  hemorrhage  (in  view  of  a  failure  of 
a  previous  case  to  do  well  on  an  associated  excision  operation 


Applications  Within  the  Month  and  Nose.  173 

for  the  removal  of  the  infected  glands),  a  major  bipolar  opera- 
tion was  done  on  this  date,  six  insulated  electrodes  being  in- 
serted into  the  growth  in  the  mouth  and  600  to  700  milliam- 
peres  used  for  40  minutes,  with  negative  on  the  surface  of  the 
external  growth.  At  the  expiration  of  this  time  the  internal 
electrodes  were  withdrawn  from  the  mouth  and  short  ones  in- 
serted in  the  periphery  of  the  outside  growth  with  the  nega- 
tive still  in  the  previous  position,  and  200  to  400  milliamperes 
were  applied  for  an  additional  20  minutes. 

April  27.  A  soft  mass  of  devitalized,  inodorous  tissue  was 
removed  from  the  mouth,  leaving  some  still  in  position^  A 
communicating  opening  to  the  external  wound  now  shows. 
The  difficulty  encountered  in  deglutition  is  so  great  that  arti- 
ficial feeding  through  nasal  tube  is  ordered. 

March  i.  Shortly  after  changing  the  dressings  this  morning 
a  small  amount  of  hemorrhage  was  noticed  within  the  mouth 
alnd  in  the  external  wound,  controlled  by  pledgets  of  Monsell's 
Solution  and  a  bandage.  About  an  hour  later,  however,  the 
patient's  pulse  became  rapid  and  the  heart  action  weak,  suc- 
ceeded by  temporary  improvement  under  heart  stimuli,  and 
later  by  renewed  weakness,  followed  by  death  in  about  fifteen 
hours  from  the  onset  of  the  unfavorable  symptoms. 

Autopsy  by  Dr.  McClary  showed  rupture  of  the  carotid 
artery,  which  was  surrounded  by  connective  tissue  showing 
pearly  b(5dies,  and  chicken-fat  clots  of  the  mitral  and  aortic 
orifices. 


SUMMARY    OF    NEW    SERIES    OF    MOUTH    AND    NOSE    CASES. 

Without  manifest  evidence  of  disease  after  periods  varying 
from  more  than  one  to  more  than  four  years :  10  cases,  of 
which  but  3  were  apparently  operable  in  the  ordinary  sense, 
making  about  42  per  cent,  of  successes. 

Failures  to  eradicate  disease :  10  cases,  of  which  all  were  in- 
operable in  the  ordinary  classification. 

Died  while  under  operation :  3  cases,  making  a  mortality  for 
the  operation  of  about  13  per  cent. 


CHAPTER  XL 


APPLICATIONS    TO   THE    LIPS. 


Epithelioma  of  the  Hp  is  usually  removable  with  ease  by  ex- 
cision in  its  earliest  stages,  particularly  in  the  lower  lip,  where 
a  V-shaped  incision  may  be  made  sufficiently  wide  of  the  dis- 
ease*to  include  the  whole  of  it  without  danger  of  re-infecting 
the  cut  edges,  the  shape  of  the  incision  permitting  the  tissues 
to  be  approximated  with  least  deformity;  yet  the  major  mono- 
polar ionic  operation  (or  bipolar  if  the  growth  be  sufficiently 
large)  is  a  ready  method  of  destruction  in  very  incipient 
growths,  in  which  the  ionic  destruction  need  not  involve  the 
muscular  tissue,  and  thus  results  in  no  deformity  at  all,  with  as 
much  security  against  local  recurrence  as  when  extensive  re- 
moval of  contiguous  structures  is  done.  Probably  an  even 
greater  role  could  be  played  by  'ionic  surgery  in  these 
incipient  cases  in  offering  the  patient  an  alternative  to 
a  method  greatly  dreaded,  and  thus  inducing  an  early  resort 
to  adequate  treatment.  The  mortality  from  hp  cancer  is  one 
due  to  delay  alone,  as  the  postponement  of  removal  or  destruc- 
tion may  lead  at  any  moment  to  invasion  of  the  regional  glands 
beneath  the  mandible,  changing  a  curable  case  into  one  in  which 
a  cure  by  any  method  is  problematic.  Gland  involvement  is  an 
early  feature  of  epithelioma  of  the  lower  lip  in  particular. 

Where  the  growth  is  extensive,  and  for  this  reason  scarcely 
operable  by  excision,  the  major  bipolar  operation  may  still  be 
used  with  some  hope  of  eradication,  particularly  if  the  glands 
in  the  neck  be  not  involved. 

FIRST    SERIES. 

Two  inoperable  cases  of  lip  carcinoma  were  treated  in  the 
first  series,  both  recurrent  after  excision  and  caustics,  with- 
out permanently  beneficial  results. 

SECOND    SERIES. 

No.  64.  Oncologic  Hospital.  Recurrent  Carcinoma  of 
Upper  Lip. — W.  C.  L.,  aged  50,  was  admitted  February  6, 

174 


Applications  to  the  Lips.  175 

1905.  Fourteen  months  before  he  discovered  a  small  lump 
in  the  substance  of  the  upper  lip,  to  right  of  nostril.  An  at- 
tempt to  remove  the  growth  by  excision  was  made  several 
months  ago. 

Examination  showed  an  indurated  mass  2  cm.  in  diameter  in 
right  upper  lip,  with  ulcerated  surface.  The  surrounding  in- 
duration includes  about  half  of  the  lip.  Microscopic  examina- 
tion showed  carcinoma  with  inflammatory  infiltration. 

A  monopolar  application  of  250  to  350  ma.  was  made  under 
chloroform  for  70  minutes.     On  separation  of  the  slough,  ten 
days  later,  a  minor  application  of  8  ma.  was  made  to  a  doubtful 
granulation,  and  February  26  he  was  discharged  to  the  dis- ' 
pensary. 

The  doubtful  tissue  continuing  to  show  immediately  above 
the  wound,  a  second  major  monopolar  application  of  300  to 
400  ma.  was  made  July  1 1  for  a  duration  of  60  minutes,  to  this 
upper  margin. 

August  10,  1906.  Patient  was  lost  sight  of  until  his  ap- 
pearance to-day.  He  states  that  a  remnant  of  the  disease  per- 
sisted at  the  margin  of  the  nose  until  he  entered  a  cancer 
paste  establishment  in  a  neighboring  state  and  had  the  paste 
applied.  There  is  a  clean  scar  at  present,  with  no  sign  of  the 
disease  showing. 

No.  176.  Oncologic  Hospital.  Recurrent  Carcinoma  of 
Upper  Lip. — W.  E.  B.,  aged  62,  was  admitted  from  Reading, 
Pa.,  July  10,  1905.  He  had  been  a  sailor  and  had  been  for 
years  a  heavy  drinker.  The  growth,  which  was  a  recurrence 
after  excision,  was  situated  in  the  left  upper  lip  and  angle  of 
mouth,  and  extended  some  distance  into  the  facial  and  buccal 
structure.  It  was  3^  inches  (9  cm.)  in  diameter  and  deeply 
ulcerated. 

The  method  of  operation  adopted  was  the  monopolar  ap- 
plication, under  general  anesthesia,  the  latter  being  very  poorly 
borne,  leading  to  an  imperfect  result  after  each  application, 
and  such  advance  of  the  disease  between  operations  as  to  de- 
feat their  object.  In  all,  five  major  applications  were  made 
between  July,  1905,  and  January,  1906,  each  of  300  to  600 
milliamperes  for  about  an  hour  each,  together  with  a  large 
number  of  minor  applications.  At  the  latter  date  disease  ex- 
isted in  the  upper  portion  of  the  face,  threatening  the  eye, 
and   further  active  treatment   was  abandoned.     The   disease 


176 


Applications  to  the  Lips. 


progressed  uninterruptedly,  ending  in  death  December  12, 
1906. 

A  review  of  this  case  leads  to  the  conviction  that  the  great 
extent  of  the  growth  and  the  previous  history  of  alcoholism 
should  have  dictated  the  bipolar  method  as  a  more  hopeful 
procedure. 

No.  609.  Oncologic  Hospital. — Epithelioma  of  Lower 
Lip. — U.  L.,  farmer,  aged  66,  was  referred  by  Dr.  S.  T.  Day 
of  Port  Norris,  N.  J.,  August  30,  1907.  For  twenty  years  he 
had  had  a  growth  on  the  lower  lip,  which  had  increased  greatly 


Fig.    62. — Epithelioma    of     lower    lip,     August    30,    1907. 
Case  60Q. 


during  the  last  five  months,  during  which  time  he  had  been 
under  the  x-ray  treatment.  The  appearance  of  the  growth  on 
admission  is  shown  in  the  photograph  (Fig.  62).  Microscopic 
examination  showed  squamous  epithelioma. 

August  30,  1907.  Major  monopolar  application.  300  ma. 
for  30  minutes. 

September    3.     Patient    discharged    to    care    of    Dr.    Day. 

December  13,.  1909.  Dr.  Day  reports  the  patient  in  good 
health  and  without  recurrence.     Photograph  (Fig.  63)  taken. 


Applications  to  the  Lips.  177 

No.  638.  Oncologic  Hospital.  Small  Epithelioma  of 
Lower  Lip. — J.  D.  H.,  railroad  engineman,  aged  62,  was  ad- 
mitted to  dispensary  October  3,  1907,  for  destruction  of  a 
raised  lump  on  the  lower  lip  the  size  of  a  pea,  with  indurated 
base.  It  had  been  observed  but  a  few  days,  and  was  not  pain- 
ful. No  microscopic  examination  was  made.  Two  minor  ap- 
plications of  4  and  2  milliamperes  for  twenty  minutes  were 
made  one  week  apart.  No  sign  of  disease  eighteen  months 
later. 

No.    647.     Oncologic    Hospital.     Epithelioma    of   Lower 


Fig.  63.— Appearance  of  lower  lip  in  Case  609  two  years  and  four 
^months  after  ionic  application. 

Lip.—].  McA.,  aged  71,  retired  track  foreman,  was  admitted 
November  11,  1907.  Some  thirteen  years  before  he  was 
knocked  down  by  a  moving  train,  and  a  clay  pipe  which  he 
was  smoking  was  driven  through  the  lower  lip  to  the  right 
of  median  line.  The  wound  was  stitched,  but  he  neglected  to 
return  to  the  hospital  to  have  the  stitches  removed,  the  wound 
healing  by  granulation  after  a  time.  The  present  growth  ap- 
peared eighteen  months  ago  in  the  scar  of  this  wound,  ulcera- 
tion occurring  three  months  ago.  The  photograph  (Fig.  64) 
shows  the  extent  and  appearance  of  the  neoplasm  on  admission. 


178 


Applications  to  the  Lips. 


A    microscopic    examination    showed    it    to    be    a    squamous 
epithelioma. 


Fig.  64. — Epithelioma  of  lip.     Case  647. 


Fig.  65. — Appearance  of  lip  m  Case  647  two  years  after  ionic 
destruction  of  epithelioma. 

November   14,   1907.     A  major  monopolar  application  was 
made  under  chloroform,  100  to  250  milliamperes  being  used 


Applications  to  the  Lips. 


179 


for  25  minutes.  In  seven  days  the  slough  came  away,  show- 
ing- a  healthy  wound,  and  on  December  24  he  was  discharged 
from  the  hospital  with  the  wound  healed  and  showing  no  sign 
of  disease. 

December  15,  1909.     Patient  seen,  with  no  recurrence,  and 
the  excellent  scar  shown  in  Fig.  65. 


SUMMARY  OF  SECOND  SERIES  OF  LIP  CASES 


Operable  Cases 

Inoperable  Cases 

Without   manifest 

evidence   of 

disease 

3 

Failed 

I 

Without    manifest 

evidence   of 

disease 

0 

Failed 

I 

CHAPTER  XII. 


APPLICATIONS   TO   THE    BREAST. 


The  field  of  ionic  surgery  is  more  restricted  in  mammary 
carcinoma  than  in  other  portions  of  the  body  for  two  reasons : 
the  success  that  may  attend  excision  with  the  knife  in  the  early 
stages  renders  the  use  of  this  method  in  these  stages  less  ad- 
visable than  in  some  other  localities ;  and  the  early  implanta- 
tion of  mediastinal  and  other  metastases  in  breast  cases  is  apt 
to  ultimately  defeat  complete  eradication  in  late  cases. 

Those  surgeons  who  have  the  opportunity  to  do  a  complete 
modern  excision  operation  in  an  incipient  carcinoma  of  the 
breast  without  apparent  axillary  involvement  (the  operation 
being  performed  with  a  full  appreciation  of  the  dangers  of 
operative  reinfection  and  without  a  preliminary  wounding  of 
the  growth  for  histologic  examination),  will  have  such  a  rea- 
sonable percentage  of  success  that  a  search  will  not  be  made 
for  other  methods  of  equally  local  character ;  for  the  chief 
source  of  failure  will  be  a  pre-existent  metastasis  in  a  large 
proportion  of  cases,  breast  carcinoma  being  peculiarly  liable 
to  early  metastases. 

Two  classes  of  cases,  nevertheless,  remain  for  the  major 
operation  of  zinc-mercury  ionization  in  breast  carcinoma.  One 
of  them  consists  of  incipient,  single  nodules  of  carcinoma  in 
young  women,  in  whom  a  preservation  of  the  breast  with 
eradication  of  the  carcinoma  is  highly  desirable ;  and  this  class 
includes  also  those  cases  in  which  the  diagnosis  bet\veen  a 
benign  growth  and  malignancy  is  still  somewhat  doubtful. 
The  general  practitioner,  particularly,  bears  the  responsibility 
of  decision  in  these  cases.  Shall  the  breast  be  sacrificed  at 
once  while  still  in  doubt?  If  a  specimen  be  taken  for 
diagnosis,  will  not  the  traumatism  and  cutting  of  the  veins  and 
absorbents  in  procuring  the  specimen  lead  to  metastasis  (if  not 
already  present)  during  the  time  necessary  to  obtain  the 
opinion  of  the  pathologist?  Of  one  question  he  will  have  no 
doubt,  and  that  is  that  mere  excision  of  the  nodule  is  not  to  be 
thought  of  for  a  moment  if  it  is  malignant. 

i8o 


Applications  to  the  Breast.  i8i 

Under  these  circumstances  a  bipolar  destructive  ionization 
of  the  nodule  and  its  immediate  surrounding-  tissues,  within 
five  minutes  after  taking  the  specimen  for  biopsy,  is  the 
proper  course.  To  this  may  be  added  a  similar  destruction 
of  any  suspicious  axillary  tissues  at  the  same  operation,  or 
later.  Should  the  careful  study  of  the  specimen  by  the  pathol- 
ogist then  result  in  a  verdict  of  benignity,  no  special  harm 
is  done,  while  a  verdict  of  malignancy  finds  the  patient  as  per- 
fectly protected,  it  is  believed  by  the  author,  as  if  the  breast 
had  been  removed  and  the  axilla  cleaned  out. 

If  there  be  cancerous  cells  in  distant  portions  of  the  breast 
this  course^will  fail  to  remove  them,  of  necessity,  and  it  should 
be  restricted  to  cases  showing  a  single  nodule.  Should  the 
nodule  prove  to  be  a  cyst,  as  sometimes  happens,  the  ionic  de- 
struction is  the  best  course  to  pursue  in  this  case  also,  dis- 
posing effectually  of  the  possibility  of  a  malignant  infection  of 
the  cyst  subsequently,  the  process  being-  an  excellent  method  of 
eradicating  a  cystoma  in  this  situation.  The  removal  of  all 
disease  from  the  axilla  by  this  method  is  as  certain,  if  not  more 
certain,  than  is  possible  by  excision  en  masse. 

The  other  class  of  cases  in  which  ionic  sterilization  is  prefer- 
able are  those  more  advanced  carcinomas  of  the  breast,  still 
apparently  free  from  metastasis,  in  which  the  growth  is  so 
closely  adherent  to  the  chest  wall,  and  presents  such  distinct 
evidences  of  axillary  involvement,  as  to  present  a  poor  prospect 
of  eradication  by  excision.  There  is  no  question  of  our  abil- 
ity to  eradicate  the  disease  in  the  deep  structures  of  a  semi- 
adherent  'growth  by  these  methods  in  some  instances  when  ex- 
cision is  impossible.  Even  the  outer  surfaces  of  the  ribs  may 
be  cleared  oft"  by  ionic  sterilization,  without  danger  of  operative 
reinfection;  while  a  bipolar  destruction  of  axillary  structures 
is  so  thorough  and  free  from  re-implantation  dangers  that  it 
may  be  employed  usefully  even  when  it  is  thought  feasible  to 
remove  the  breast  itself  by  the  knife.  It  is  true,  of  course, 
that  the  final  result  of  all  of  this  latter  class  of  cases  is  likely 
to  be  an  ultimate  failure  of  the  vital  powers  by  the  continued 
progress  of  unrecognized,  pre-existent  metastatic  deposits,  of 
the  existence  of  which  at  the  time  of  the  operation  we  have  na 
means  of  knowing  in  spite  of  blood  examinations ;  yet  the  pa- 
tient's sufferings  are  greatly  relieved  by  a  permanent  removal 
of  the  local  disease. 


l82 


Applications  to  the  Breast. 


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Applications  to  the  Breast.  185 

On  the  whole,  in  carcinoma  of  the  breast,  as  in  other  por- 
tions of  the  body,  excision  is  to  be  recommended  as  quicker 
and  involving  a  shorter  stay  in  the  hospital,  if  the  disease  can 
be  excised  entire  without  wounding  its  structure,  with  the  spe- 
cial reservation  that  this  necessarily  implies  a  complete  am- 
putation of  the  organ,  and  that  in  certain  young  women  the 
zinc-mercury  ion  method  renders  the  latter  unnecessary. 
When  the  success  of  the  excision  is  rendered  doubtful  by  fix- 
ation to  the  chest  wall  or  invasion  of  the  axilla  the  ionic 
method  presents  greater  possibilities  of  success  in  actual  eradi- 
cation, and  is  more  scientific  as  a  palliative. 

Contraindications  of  Ionic  Surgery  in  Mammary  Carcinoma. 
—If  the  fixation  and  immobility  of  the  carcinoma  are  of  such 
character  and  long  duration  as  to  indicate  extension  of  the 
disease  within  the  chest  cavity,  ionic  or  any  other  kind  of 
surgery  will  do  harm  and  can  do  no  good.  The  same  is  true  of 
infection  of  the  supraclavicular  glands,  or  of  the  sub-dermic 
extension  of  the  disease  known  as  cancer  en  cuirasse.  Too  low 
a  percentage  of  hemoglobin  also  contraindicates  surgical  inter- 
vention of  any  kind. 

FIRST  SERIES  (see  Tables,  pages  182,  183,  and  184). 

The  most  striking  facts  to  be  gathered  from  the  above  tab- 
ulation of  the  twenty  cases  of  breast  carcinoma  placed  under 
destructive  ionization  prior  to  1905  are:  (i)  That  though  one 
patient,  the  sixth  on  the  list,  is  still  living,  and  her  present 
freedom  from  the  disease  may  be  partly  due  to  the  imperfect 
ionic  operation  done  eleven  years  ago,  none  of  the  patients  were 
cured  by  these  early  ionic  operations.     (2)    That,   with  the 
above  exception,   all   were  inoperable   in   the  ordinary  sense 
when  received  for  treatment,  eleven  being  also  recurrent  after 
excision;  yet,  in  spite  of  these  deplorable  conditions,  eight  of 
the  nineteen  inoperable  cases  were  greatly  relieved  in  local  and 
general  health,  and  their  lives  prolonged,  while  others  were 
temporarily  benefited.     (3)  That  these  extremely  vigorous  ef- 
forts to  ascertain  the  value  of  major  ionic  surgery  in   un- 
selected  cases  of  inoperable  cancer  of  the  breast  resulted  in  but 
one  death  from  secondary  hemorrhage,  probably  preventable 
and  no  operative  deaths. 

The  failure  to   eradicate  the   disease  in   the   one  operable 


i86  Applications  to  the  Breast. 

case  in  the  list  was  evidently  due  to  faulty  technic  early  in 
the  development  of  the  method  (1898).  In  this  case  a  gold- 
mercury  electrode  was  used,  a  technic  abandoned  in  more  re- 
cent cases  for  zinc-mercury  points,  it  being  found  impossible 
to  localize  the  effect  so  accurately  with  the  gold  electrode  and 
fluid  mercury  as  with  the  zinc-mercury  points. 

SECOND    SERIES. 

No.  46.  Oncologic  Hospital.  Carcinoma  of  Breast. — 
Mrs.  S.  G.  was  referred  by  Dr.  E.  C.  Hough  of  Villisca,  Iowa, 
February  8,  1905.  Four  or  five  years  ago  she  noticed  a  tumor 
in  the  right  breast.  During  the  past  year  Dr.  Hough  has 
applied  the  x-ray,  the  last  application  having  been  six  months 
ago,  when  it  was  stopped  by  reason  of  the  appearance  of  a 
dermatitis. 

Examination  showed  the  whole  of  the  breast  indurated  and 
fixed  to  the  chest  wall,  with  a  large  ulceration  occupying  two- 
thirds  of  the  tumor.  No  glands  were  infected.  The  pa- 
tient's color  was  bad. 

February  10,  1905.  Under  general  anesthesia,  a  monopolar 
application  of  560  milliamperes  was  made  for  forty  minutes, 
but  as  this  amount  could  not  be  increased  by  reason  of  poor 
respiration  the  application  was  then  changed  to  bipolar  and  a 
current  of  1500  milliamperes  applied  for  twenty  minutes,  with 
a  dozen  electrodes.  The  separation  of  the  slough  was  without 
incident,  but  showed  some  induration  on  the  sternal  edge  of 
the  wound,  for  which  two  minor  applications  of  60  and  100 
milliamperes  were  made  during  March  and  April.  The  in- 
duration remaining  in  the  skin  itself  was  attacked  April  26  by  a 
second  major  monopolar  application  under  anesthesia.  Two 
more  minor  applications  to  suspicious  granulations  were  re- 
quired on  June  17  and  July  14,  and  the  patient  was  discharged 
from  observation  in  September  with  the  wound  thoroughly 
healed  and  showing  no  evidence  of  disease.  The  general  health 
had  also  improved. 

June  3,  1908.  Dr.  Hough  writes  that  the  patient  died  on 
this  date  of  an  affection  of  the  chest,  supposed  to  be  la 
grippe,  of  which  she  had  suffered  for  some  months,  but  that 
there  was  no  recurrence  of  the  disease  apparent. 

No.  85.  Oncologic  Hospital.  Recurrent  Carcinoma  of 
Breast,  with  Metastasis. — Mrs.  L.  W.,  aged  75,  was  admitted 


Applications  to  the  Breast.  187 

September  4,  1905,  for  local  treatment  of  a  large  carcinomatous 
ulceration  of  the  right  breast,  following  a  caustic  paste  applica- 
tion nine  years  before.  Palliation  alone  was  aimed  at,  as  the 
patient  was  profoundly  cachectic.  A  major  monopolar  ap- 
plication of  400  milliamperes  was  made  for  45  minutes.  Re- 
sult :  improvement,  but  not  local  eradication. 

No.  123,  Oncologic  Hospital.  Recurrent  Carcinoma  of 
Right  Breast. — Mrs.  K.  E.,  aged  34,  was  admitted  May  11, 
1905.  Three  years  before  she  had  been  struck  in  the  affected 
breast.  Three  months  later  a  hard  lump  appeared  at  the  site 
of  the  injury  and  was  treated  by  a  caustic  plaster,  the  present 
growth  appearing  seven  months  ago  and  being  more  rapid  in 
development  than  the  original  one. 

There  is  an  ulcerated,  proliferating  growth  involving  the 
whole  breast  and  about  the  size  of  an  orange.  There  is  some 
axillary  involvement,  and  radiating  pain  to  shoulder  and  arm. 
Microscopic  examination  showed  squamous-cell  carcinoma. 

A  major  monopolar  application  of  600  to  800  milliamperes 
for  one  hour  was  made  May  13.  The  slough  separated  with- 
out incident,  and  June  9  she  was  discharged  to  the  dis- 
pensary with  a  healthy  wound  nearly  healed  over.  The  pa- 
tient failed  to  return  to  the  hospital  again,  and  diligent  inquiry 
elicited  the  information  some  months  later  that  she  was  in 
poor  health. 

No.  125.  Oncologic  Hospital.  Carcinoma  of  Right 
Breast. — Mrs.  L.  H.,  aged  61,  was  admitted  May  4,  1905,  with 
a  complete  involvement  of  the  right  breast  in  a  proliferating 
mass,  deeply  ulcerated.  The  patient  first  noticed  a  lump  in  the 
breast  thirteen  months  before,  the  ulceration  being  recent. 
There  were  no  apparent  enlargements  of  the  glands,  though 
some  evidences  of  cachexia  were  present.  Microscopic  ex- 
amination showed  cylindrical-cell  carcinoma. 

A  major  bipolar  application  of  700  milliamperes  for  one  hour 
was  made  May  8,  under  general  anesthesia,  the  ionic  destruc- 
tion being  extended  to  the  apex  of  the  axilla.  The  slough 
separated  without  incident,  and  she  was  discharged  to  the  dis- 
pensary June  9  with  uncertain  granulations  on  the  bottom  of 
the  wound,  being  given  directions  to  return  regularly  for  ob- 
servation. 

The  patient  did  not  return  to  the  dispensary,  and  word  was 
received  some  months  later  that  she  was  under  x-ray  treatment 
in  another  hospital  for  a  recurrence. 


i88  Applications  to  the  Breast. 

Xo.  198.  Oncologic  Hospital.  Carcinoma  of  Right 
Breast,  zvith  Metastasis. — ]\Iiss  I.  E.  L.,  aged  52,  was  admitted 
July  31,  1905.  Four  3-ears  before  a  growth  was  noticed  in  the 
right  breast,  which  was  allowed  to  grow  steadily  since  without 
elTort  at  remedy.  Of  late  the  general  health  has  become  poor, 
and  there  is  evidence  of  metastasis  and  cachexia.  The  growth 
is  the  size  of  half  a  cocoanut,  ulcerated  in  the  center,  and 
slightly  adherent  to  the  chest  wall.  It  extends  into  the  axilla 
and  below  the  axilla  on  the  chest.  Microscopic  examination 
showed  it  to  be  a  carcinoma. 

August  2.  It  was  decided  to  give  the  patient  local  re- 
lief, and  on  this  day  she  received  a  major  bipolar  application 
of  1200  to  1600  milliamperes  for  75  minutes,  under  general 
anesthesia. 

October  5.  The  wound  is  healthy  except  at  the  lower  edge. 
Second  major  bipolar  application  of  300  to  350  milliamperes 
for  10  minutes.  The  recovery  from  the  anesthetic  was  pro- 
longed, and  shortly  after  an  aphasic  condition  developed,  ac- 
companied by  pain  in  the  right  leg.  She  was  seen  in  con- 
sultation by  Dr.  Chas.  K.  Mills,  who  thought  the  aphasic  symp- 
toms due  to  metastasis  to  the  brain.  The  cachectic  condition, 
which  had  been  marked  on  admission,  gradually  returned, 
and  the  patient  died  of  general  inanition  some  months  later, 
without  local  recurrence. 

No.  257.  Oncologic  Hospital.  Carcinomatous  Nodule  in 
Left  Breast,  zvith  Axillary  Involvement. — Miss  I.  M.  T.,  aged 
25,  was  admitted  October  30,  1905,  with  a  movable  tumor  in 
the  upper,  outer  quadrant  of  the  left  breast.  The  tumor  had 
been  first  noticed  two  or  three  years  before,  was  painless,  but 
lately  had  increased  rapidly  in  size. 

Examination  shows  a  movable  tumor  no  larger  than  a  peach 
stone,  with  irregular  edges.  No  enlargements  of  the  axillary 
or  supra-clavicular  glands  could  be  detected,  arid  the  patient's 
general  health  is  good. 

October  31,  1905.  The  clinical  indications  pointing  to  car- 
cinoma of  the  breast  in  its  earliest  stage,  which  were  subse- 
quently verified  by  the  microscopic  examination  showing 
squamous-cell  carcinoma,  it  was  decided  to  save  the  breast,  if 
possible,  by  destroying  the  tumor  in  situ.  She  was  accord- 
ingly placed  under  general  anesthesia  on  this  date,  a  specimen 
removed  for  histologic  examination,  and  a  bipolar  application 


Applications  to  the  Breast. 


189 


of  200  to  350  milliamperes  made  for  50  minutes.  The  slough 
separated  without  incident  and  the  patient  was  discharged  to 
the  dispensary  November  18.  On  January  10,  1906,  a  minor 
application  of  10  ma.  was  made  to  a  doubtful  granulation  for 
eight  minutes. 


Fig.  66. — Photograph  of  scar^  in  breast  and  axilla  of  a  young  woman, 
four  years  after  ionic  eradication  of  carcinomatous  nodule  in  breast 
and  three  years  after  similar  eradication  of  carcinomatous  gland  in 
the  axilla.     The  breast  is  practically  intact. 


September  25,  1906.  Patient  re-admitted  for  the  destruction 
of  an  enlarged  gland  in  anterior  portion  of  left  axilla.  In  July 
she  was  admitted  for  the  same  purpose,  having  been  kept  under 
monthly  observation   for  the  particular  purpose  of   watching 


190  Applications  to  the  Breast. 

the  axilla,  but  on  placing  her  on  the  table  at  that  time  the  en- 
larged gland  could  not  be  found.  It  is  more  evident  now,  being 
about  the  size  of  a  pea.  It  was  decided  to  destroy  all  tissues 
in  the  axilla  as  a  precautionary  measure.  She  was  accord- 
ingly anesthetized,  an  electrode  thrust  through  the  skin  into 
the  gland,  and  300  to  400  milliamperes  applied  monopolar  for 
30  minutes  with  six  electrodes  to  the  whole  thoracic  portion  of 
the  axilla.  (Remark:  There  is  no  reason  why  the  application 
should  not  have  been  bipolar,  considering  the  proximity  of  the 
heart,  with  equally  good  results.) 

The  photograph  (Fig.  66)  shows  the  four-year-old  scar  of 
the  first  operation  in  the  breast,  and  the  three-year-old  scar  of 
the  second  operation  in  the  axilla,  as  they  appear  at  present. 

The  patient  is  in  perfect  health  and  without  recurrence  at 
the  present  time,  November,  1909,  four  years  after  the  first 
operation  and  three  years  after  the  second. 

No.  258.  Oncologic  Hospital.  Carcinomatous  Nodule  in 
Breast. — Miss  P.,  aged  46,  was  referred  by  Dr.  N.  E.  Smith 
of  Fayette,  Mo.,  November  3,  1905.  For  two  or  three  years 
she  had  noticed  a  nodule  in  the  left  breast  which  was  at 
first  movable,  but  of  late  had  grown  more  fixed.  It  has  not 
given  rise  to  pain.  Her  mother  had  died  of  cancer  of  the 
stomach. 

Examination  shows  a  flattened  induration  in  upper,  inner 
quadrant  of  the  left  breast  about  two  inches  in  diameter, 
somewhat  adherent  to  the  overlying  skin  and  free  from  special 
sensation. 

November  4,  1905.  A  major  bipolar  application  was  made 
under  ether,  275  to  450  milliamperes  being  employed  for  20 
minutes.  The  specimen  removed  showed  carcinoma.  Separa- 
tion of  slough  and  healing  were  uneventful,  and  the  patient 
was  discharged  without  manifest  evidence  of  disease  January 
8,  1906. 

November  17,  1909.  Letter  received  saying  scar  is  healthy 
and  that  there  is  no  sign  of  recurrence. 

No.  275.  Oncologic  Hospital.  Carcinoma  of  Breast  and 
Axilla,  with  Metastasis. — Miss  K.  R.,  aged  46,  was  admitted 
from  Pittsburgh,  Pa.,  December  18,  1905.  Her  mother  had 
cancer  of  the  hand  and  a  sister  has  cancer  of  the  breast.  Six 
months  ago  the  lump  was  first  noticed  in  the  right  breast;  but 
it  has  grown  so  rapidly  that  at  the  present  time  the  whole 


Applications  to  the  Breast.  191 

breast  is  infiltrated  and  the  overlying  skin  reddened  and  about 
to  break  down.  There  is  a  group  of  enlarged  glands  in  the 
axilla,  and  the  patient  presents  evidence  of  metastasis  and 
moderate  cachexia. 

December  21,  1905.  To  give  the  patient  the  benefit  of  the 
doubt  as  to  the  presence  of  metastasis  a  major  bipolar  applica- 
tion was  made,  under  ether,  800  to  1800  milliamperes  being  em- 
ployed for  70  minutes  to  both  breast  and  axilla.  After  the 
separation  of  the  very  large  slough  the  outer  surfaces  of  three 
ribs  were  exposed,  and  during  the  healing  an  obstinate  sinus 
developed  in  the  tissues  of  the  chest  wall  below  the  wound. 
Evidence  of  metastasis  to  the  brain  developed  later,  and  the 
patient  was  taken  home  in  a  poor  mental  condition  April  7, 
but  with  the  wound  healed  and  showing  no  local  evidence  of 
the  disease.  The  mental  symptoms  increased  in  severity,  re- 
sulting in  death  shortly  after  from  metastasis. 

No.  277.  Oncologic  Hospital.  Carcinoma  of  Left 
Breast. — Miss  M.  A.  H.,  aged  63,  was  admitted  from  Law- 
renceville,  N.  J.,  December  20,  1905.  Five  months  before  she 
had  first  noticed  a  tumor  in  the  left  breast  near  the  nipple. 
It  has  increased  rapidly  since,  and  is  the  seat  of  lancinating 
pains. 

The  central  portion  of  the  left  breast  is  indurated,  though 
movable  on  the  chest  wall,  and  the  nipple  deeply  retracted. 
A  group  of  enlarged  glands  is  found  in  the  axilla,  but  no  ap- 
preciable evidence  of  infected  supraclavicular  glands.  The 
general  health  was  poor,  with  some  renal  disturbance. 

After  attempts  to  improve  the  general  health,  a  major 
bipolar  application  was  made,  under  ether,  800  to  1800  milli- 
amperes being  used  for  45  minutes  to  breast  and  axilla.  The 
slough,  apparently  including  the  entire  breast  and  the  contents 
of  the  axilla,  separated  January  19  without  incident,  and  the 
patient  was  discharged  with  an  excellent  scar  April  27.  The 
general  health  improved  steadily  for  a  year  or  more,  and  no 
evidence  of  the  presence  of  metastasis  in  the  supraclavicular 
glands  showed  until  the  expiration  of  one  year  and  nine  months 
from  the  operation,  when  a  chain  was  noticed  October  i,  1907, 
extending  from  the  clavicle  to  the  post-auricular  region.  She 
was  re-admitted  to  the  hospital  a  week  later,  with  the  cervical 
glands  grown  decidedly  larger  in  the  interim,  and  distinct  evi- 
dence of  recurrence  in  the  wound  was  also  noticed.     Patient 


192  Applications  to  the  Breast. 

was  placed  on  the  x-ray  treatment,  but  failed  steadil}",  and 
died  a  year  later. 

Xo.  280.  OxcoLOGic  Hospital.  Carcinoma  of  Right 
Breast. — ]\Iiss  A.  B.,  aged  33,  was  admitted  December  29,  1905. 
Family  history  negative.  Two  years  ago  a  tumor  in  the  center 
of  the  left  breast  was  jioticed,  but  its  existence  was  concealed 
by  the  patient  until  she  was  suddenly  attacked  by  an  arterial 
hemorrhage  early  in  the  morning  two  days  ago.  She  was  seen 
by  Dr.  John  B.  Deaver  the  same  day  and  was  referred  by  him 
to  the  Oncologic  Hospital. 

On  examination,  the  whole  of  the  left  breast  was  found  to 
be  infiltrated  with  the  growth,  the  central  portion  being  broken 
down  into  a  large  cavity,  at  the  bottom  of  which  was  a  bleed- 
ing artery.  It  was  learned  that  she  had  been  ill  for  six 
months  past,  during  which  time  but  little  food  had  been  re- 
tained on  the  stomach.  Her  temperature  was  102,  and  her 
appearance  exsanguine.  A  severe  hemorrhage  occurred  dur- 
ing the  inspection,  and  she  was  sent  to  the  hospital  at  once. 

^December  29,  1905.  On  arrival  of  the  patient  at  the  hos- 
pital she  was  placed  on  the  table  for  a  major  bipolar  operation, 
which  was  done  without  complete  removal  of  the  packing  and 
bandages,  as  it  was  feared  that  another  hemorrhage  would  be 
fatal.  A  large  bipolar  negative  electrode  was  placed  on  the 
central  packing  of  the  cavity,  which  was  wetted  with  a  weak 
solution  of  sulphuric  acid  and  water;  long  active  zinc- 
mercury  breast  electrodes  were  inserted  between  the  growth 
and  ribs,  the  tips  meeting  in  the  center;  and  a  current  of  1900 
to  2000  ma.  turned  on  and  maintained  for  75  minutes,  a  speci- 
men being  meantime  removed  for  microscopic  examination. 
The  procedure  was  successful  in  sealing  the  large  arter}^  that 
had  been  eroded  by  the  disease,  and  at  the  end  of  the  time 
mentioned  the  whole  of  the  diseased  breast  and  axillary  struc- 
tures were  devitalized  and  converted  into  a  gray,  dry  crust. 
The  temperature,  which  was  10 1.4  before  operation,  fell  to  nor- 
mal the  same  night  and  remained  normal  several  days,  rising 
above  normal  only  a  few  days  during  the  separation  of  the 
slough,  which  was  removed  on  the  fifteenth  day,  showing  a 
large,  healthy  wound,  to  which  the  violet  ray  was  applied  to 
hasten  granulation. 

The  convalescence  of  the  patient  was  uneventful,  though 
prolonged  on  account  of  the  large  surface  to  be  cicatrized,  the 


Applications  to  the  Breast.  193 

wound  extending  well  up  into  the  axilla.  She  was  discharged 
to  the  dispensary  April  13,  1906,  with  a  healthy  wound,  but 
with  an  obstinate  sinus  extending  into  the  cellular  tissues  from 
the  lower  edge  of  the  wound  for  which  she  was  referred  to  Dr. 
Hewson,  being  finally  discharged  from  the  dispensary  without 
manifest  evidence  of  disease  some  months  later. 

The  patient  died  in  June,  1908,  of  spinal  meningitis,  with  a 
perfect  scar  and  no  evidence  of  recurrence.  No  autopsy  was 
available. 

No.  304.  Oncologic  Hospital.  Carcinoma  of  Breast, 
Axilla  and  Supraclavicular  Region,  with  Metastasis. — Mrs.  A. 
K.,  aged  yy,  was  admitted  February  3,  1906,  for  temporary  al- 
leviation while  waiting  for  admission  to  the  Home  for  In- 
curables. There  was  a  large  denuded  area  occupying  the  site 
of  the  right  breast,  being  a  carcinoma  recently  under  caustic 
treatment  by  an  irregular  practitioner.  The  axillary  and 
supraclavicular  glands  were  largely  involved.  A  major 
monopolar  application  of  350  ma.  for  30  minutes  was  made 
to  the  broken  down  tissues,  followed  by  a  series  of  ultra- 
violet ray  applications,  and  the  patient  was  discharged  to  the 
Home  September  4,  in  an  improved  condition. 

No.  338.  Oncologic  Hospital.  Carcinoma  of  Right 
Breast. — Mrs.  T.  ^y.,  aged  49,  was  referred  by  Dr.  Frank  O. 
Stem  of  Berlin,  N.  J.,  May  2,  1906.  The  growth  involved 
the  greater  portion  of  the  right  breast,  with  greatest  pro- 
trusion downwards :  had  existed  for  two  years  to  the  patient's 
knowledge,  becoming  painful  five  weeks  ago.  It  is  hard,  and 
the  skin  is  adherent  over  the  most  prominent  portion,  with  dis- 
tinct retraction  of  the  nipple.  It  extends  into  the  lower  axil- 
lary space,  but  there  are  no  separate  glandular  enlargements  in 
this  region  nor  in  the  supraclavicular  region.  Microscopic  ex- 
amination of  specimen  showed  carcinoma.  The  patient's  gen- 
eral health  was  poor  and  the  urine  contained  traces  of  al- 
bumen. 

After  ten  days'  treatment  of  the  general  health,  the  patient 
was  placed  under  chloroform  and  a  major  bipolar  application 
made  of  800  to  1600  ma.  for  70  minutes,  the  electrodes  in- 
cluding the  axillary  projection  and  most  of  the  axillary  tissues 
in  the  field  of  sterilization.  The  separation  of  the  large  slough 
was  uneventful,  and  by  the  end  of  seven  weeks  the  condition 
of  the  cicatrizing  wound  permitted  her  return  home,  with  in- 


194  Applications  to  the  Breast. 

structions  to  report  at  intervals.  This  was  not  done  very  reg- 
ularly, and  on  a  visit  on  December  9,  1907,  a  suspicious  scab 
was  noted  in  the  center  of  the  scar,  which,  however,  did  not 
represent  recurrence  of  the  disease,  as  it  healed  nicely  on  re- 
moval of  the  scab  and  the  use  of  zinc  oxide  ointment. 

At  the  present  time,-  July,  1909,  over  three  years  after  treat- 
ment, there  is  no  evidence  of  either  recurrence  or  of  a  pre- 
operatively-implanted  metastasis. 

Xo.  504.  OxcoLOGic  Hospital.  Carcinoma  of  Breast, 
Fulminating  Type. — ^Irs.  S.  AI.,  aged  52,  was  admitted  Janu- 
ary 3,  1907.  Seven  months  before  she  injured  the  lower  por- 
tion of  the  left  breast  by  a  broken  corset  steel,  a  tumor  that 
was  painful  and  quick-growing  being  recognized  at  the  site 
of  the  injury  several  months  later. 

Though  the  known  history  of  the  growth  is  thus  covered  by 
seven  months,  it  was  found  to  be  a  large,  reddened  cystic 
mass,  5  by  6  inches  (13  by  15  cm.)  in  diameter  and  involving 
nearly  the  whole  of  the  breast,  and  apparently  adherent  to  the 
chest  wall.  She  was  placed  under  a  major  bipolar  operation 
January  4,  under  ether,  2000  milliamperes  being  employed  with 
nimierous  electrodes  for  one  and  a  half  hours. 

The  patient  recovered  strength  imperfectly  after  the  opera- 
tion, evidencing  probably  general  metastasis,  and  showed, 
moreover,  remnants  of  the  disease  in  the  bottom  of  the  wound 
after  the  separation  of  the  slough,  these  remnants  increasing 
rapidly  in  extent.  Elinor  applications  were  begun  January  21, 
as  much  as  350  and  400  ma.  being  employed  at  first,  bipolar, 
without  severe  pain,  and  on  February  20  another  major  bipolar 
operation  was  done,  with  1400  to  1800  ma.  for  50  minutes. 

On  ^larch  13  the  increasing  weakness  as  an  indication  of  in- 
ternal metastasis  was  supplemented  by  the  appearance  of 
raised,  yellowish  pink  bullse  on  a  reddened  and  indurated  base 
in  several  situations,  notably  the  forehead,  arms  and  fingers, 
arising  apparently  in  the  skin  itself  and  greatly  resembling  in 
appearance  the  original  growth.  These  continued  to  multiply 
and  grow  larger  until  her  death,  ]\Iay  31,  of  asthenia. 

Xo.  88.  Private  Case  Book.  Recurrent  Carcinoma  of 
Right  Breast. — Mrs.  O.,  aged  42,  applied  for  treatment  of  a 
recurrent  growth  of  the  right  breast,  April  9,  1907.  The  breast 
had  been  removed  some  months  before  by  excision,  the  growth 
promptly  returning,  the  site  of  operation  being  covered  by  car- 


Applications  to  the  Breast.  195 

cinomatoiis  nodules  that  adhere  firmly  to  the  chest  wall.  The 
patient  was  extremely  anemic,  and  probably  cachectic  from  ex- 
tensive internal  metastases,  but  to  give  her  the  benefit  of  a  last 
resort,  was  placed  under  a  major  monopolar  application  at  her 
home,  April  10.  She  bore  the  chloroform  badly,  and  shortly 
after  a  current  of  300  to  400  milliamperes  had  been  attained, 
suddenly  expired — whether  from  the  anesthetic  or  from  inhibi- 
tion of  the  respiratory  innervation  by  the  current  could  not  be 
determined. 

No.  dyS.  Recurrent  Carcinoma  of  Left  Breast. — Mrs.  V., 
aged  50,  was  admitted  January  20,  1908.  Four  years  ago  a 
small  tumor  was  "  rolled  out "  of  its  capsule  in  the  upper, 
outer  quadrant  of  the  left  breast  by  a  distinguished  surgeon 
of  the  city,  who  pronounced  the  growth  benign.  Six  months 
later  the  part  was  accidentally  injured  by  a  blow,  followed  by 
the  development  of  the  present  growth.  She  has  had  over  two 
hundred  x-ray  applications  during  the  past  eighteen  months. 

The  upper  and  outer  two-thirds  of  the  breast  is  the  site  of  a 
raised  induration,  5  by  3  inches  (13  by  8  cm.)  in  area,  center- 
ing around  the  old  scar,  with  the  nipple  somewhat  fixed  and 
retracted.  In  the  axilla  there  are  at  least  three  enlarged  glands, 
the  largest  about  the  size  of  a  hen's  egg.  The  patient's  general 
health  indicated  the  possibility  of  metastasis,  as  she  was  pale 
and  apparently  cachectic.  Microscopic  ^  examination :  car- 
cinoma. 

January  31,  1908.  Major  bipolar  application,  under  ether, 
1900  to  2000  milliamperes  for  one  hour  and  fifteen  minutes. 
A  large  slough  separated  in  the  usual  time,  without  incident, 
but  revealing  quite  an  area  of  diseased  tissue  that  had  been 
missed  in  the  upper  angle  of  the  axilla.  This  was  attacked 
by  minor  applications  beginning  February  26  and  ending  two 
months  later,  during  which  time  eighteen  applications  were 
made,  varying  from  60  to  30  milliamperes,  for  a  half-hour 
each.  An  attack  of  erysipelas  contracted  from  another  pa- 
tient interfered  with  treatment  at  this  time,  and  on  May  14 
the  patient  was  discharged  to  office  care,  three  more  small 
minor  applications  being  made  in  the  following  month. 

August  21.  Photograph  (Fig.  68)  taken,  showing  an  excel- 
lent scar  and  no  sign  of  disease.  The  patient  has  gained  con- 
siderably in  weight  and  general  health,  but  the  ominous  pale- 
ness persists. 


196 


Applications  to  the  Breast. 


The  excellent  health  gained  by  the  patient  began  to  fail 
during  the  following  winter,  evidently  from  metastasis  of  long 
standing.  Difficult  respiration  finally  ensued,  and  on  the  25th 
of  August,  1909,  the  patient  died  of  asthenia,  without  local 
recurrence.     No  post-mortem  examination  was  available. 

No.  808.  Oncologic  Hospital.  Recurrent  Carcinoma  of 
Left  Breast. — Mrs.  M.,  aged  40,  was  referred  by  Dr.  W.  W. 


Fig.  67. — Appearance  of  wound  after  separation  of  devitalized 
tissue  in  Case  676.  The  axillary  portion  of  wound  shows  un- 
destroj^ed  cancerous  tissue,  subsequently  eradicated  by  minor 
applications. 

E.ay  of  Springfield,  Ky.,  September  3,  1908.  The  primary 
growth  was  removed  by  excision  January  8,  1909,  a  second 
operation  for  recurrent  nodules  in  wound  being  made  in  the 
following  July. 

There  are  a  large  number  of  recurrent  nodules  beneath  the 
skin  near  the  scar  of  the  excision  operations,  and  a  subdermic 
abscess  beneath  the  lower  angle  of  the  scar^  The  axilla  and 
supraclavicular  regions  seem  to  be  free  from  the  disease,  but 
the  wasted  condition  of  the  patient  suggested  a  strong  prob- 
ability of  metastasis  to  internal  organs,  though  her  color  was 


Applications  to  the  Breast. 


197 


fairly  good.     Blood  count :  Erythrocytes  4,200,000 ;  leukocytes 
9,200;  hemoglobin  60  per  cent. 

September  5,  1908.  Major  bipolar  application  under  ether, 
400  to  800  milliamperes,  four  to  six  needles  to  each  spot,  for  a 
total  time  of  40  minutes,  the  negative  being  held  against  each 
spot  in  turn  by  an  assistant. 


Fig.  68. — Case  676  after  complete  healing. 

October  6.     Minor  application   of   15   milliamperes    for   30 
minutes  to  a  shot-like  body  beneath  skin  above  wound. 

October  13.  Patient  discharged  to  dispensary  with  healing, 
healthy  wound.  Small  nodules,  the  size  of  bird  shot,  situated 
beneath  the  skin  at  a  distance  from  the  edges  of  the  wound  re- 
ceived minor  applications  October  17  and  20  and  November 
2,  6,  9,  21  and  December  i  and  8.  Also,  on  November  2  a 
gland  beneath  the  clavicle,  just  external  to  outer  attachment 
of  the  sterno-cleido-mastoid  muscle,  was  found  to  be  enlarged 
to  size  of  a  large  pea  and  was  destroyed  by  an  ionic  needle  in- 


198 


Applications  to  the  Breast. 


serted  through  the  skin,  under  novocaine  local  anesthesia,  15 
milliamperes  being  used  for  30  minutes. 

December  17.  Patient  went  home  on  account  of  continu- 
ing weakness  and  evidence  of  metastasis  to  the  chest,  with  the 
local  conditions  greatly  improved.  Report  received  of  in- 
creasing weakness  and  difficulty  in  breathing  after  her  return 
home,  and  of  her  death  February  16,  1909. 

No.  990.  Oncologic  Hospital.  Carcinoma  of  Right 
Breast. — Mrs.  J.  S.,  aged  50,  was  referred  by  Dr.  Stuart  C. 
Runkle  July  30,  1909.  She  had  had  a  small  movable  lump 
in  the  upper,  outer  quadrant  of  the  right  breast  since  puberty. 
One  year  ago  it  began  to  enlarge,  becoming  ulcerated  and 
painful  five  months  ago. 

Examination  shows  a  cauliflower-like  growth,  4  by  5  inches 
in  diameter,  projecting  from  front  of  breast,  with  eroded  sur- 
face. It  is  somewhat  movable  on  the  chest  wall.  There  is  a 
large  tumor  in  the  axilla  near  its  anterior  border  and  several 
palpable  glands,  and  a  distinctly  palpable  enlarged  gland  im- 
mediately behind  the  clavicle.  The  patient  is  thin,  of  poor 
color,  and  probably  cachectic.  Blood  count:  red  blood 
corpuscles  4,444,000;  leucocytes  11,440;  hemoglobin  80  per 
cent.     Microscopic  examination :  carcinoma. 

July  31,  1909.  ]\Iajor  bipolar  application  under  ether,  600  to 
2000  milliamperes  for  one  hour,  to  breast  and  axilla. 

On  the  separation  of  the  devitalized  tissue  the  whole  region 
occupied  by  the  breast  growth  appeared  free  from  the  disease, 
but  the  axilla  showed  a  mass  of  glands  that  had  been  missed 
in  the  bipolar  operation.  These  were  attacked  by  monopolar 
minor  applications  at  once,  three  applications  of  50  to  70 
milliamperes  for  a  half  hour  each  being  made  in  September 
and  one  November  4. 

There  is  no  sign  of  recurrence  at  present,  an  excellent  scar 
covering  the  site  of  disease,  and  the  patient's  health  is  dis- 
tinctly improved. 


SUMMARY  OF  NEW  SERIES  OF  BREAST  CASES 

operable  Cases 

Inoperable  Cases 

Without   mani- 
fest   evidence 
of  disease 

4 

Failure 

I 

Without   mani- 
fest   evidence 
of  disease 

2 

Died  of 

metastasis 

without    local 

recurrence 

3 

Improved 
4 

Failure 
2 

Died 

under 

treatment 

I 

CHAPTER  XIII. 

APPLICATIONS  TO  THE   CERVIX   UTERI. 

Cancer  of  the  body  of  the  uterus  should  be  removed  by 
total  hysterectomy  when  diagnosed  sufficiently  early,  and  in 
any  stage  is  unsuitable  for  any  curative  application  of  elec- 
trical methods,  save  only  those  instances  of  atrophic  en- 
dometritis that  are  found  in  elderly  women  that  closely  ap- 
proximate malignancy  in  clinical  course,  and  that  often  yield 
to  a  prolonged  series  of  minor  applications  of  zinc-mercury 
ions. 

Of  cancer  of  the  cervix,  it  may  be  said,  on  the  contrary,  that 
the  only  efficient  surgical  remedy  at  present  known  is  the 
method  described  in  these  pages,  or  the  galvano-cautery  oper- 
ation of  the  late  Dr.  Byrne  of  Brooklyn,  as  it  is  now  known 
that  operative  re-implantation  of  the  disease  is  an  almost  cer- 
tain accompaniment  of  a  cutting  operation  in  the  confined 
area  within  which  the  operator  is  compelled  to  work.  Yet, 
in  spite  of  the  adaptability  of  the  sterilization  method  to  the 
destruction  of  cancers  within  cavities  of  this  nature,  but  few 
cases  of  the  disease  can  be  actually  cured  at  present  for  the 
reason  that  the  patients  are  almost  invariably  seen  for  the  first 
time  after  the  disease  has  advanced  beyond  the  local  stage. 
It  is  probable  that  not  one  case  in  fifty  is  diagnosed  before  a 
purulent  discharge  or  slight  hemorrhages  occur,  yet  these  signs 
indicate  that  the  disease  has  already  progressed  to  the  stage 
of  ulceration,  and  possibly  regional  infection  of  the  glands.  In 
the  greater  number  pain  also  is  present  at  the  discovery  of  the 
growth,  and  this  indicates  an  even  later  stage.  It  is  to  be 
feared  that  early  diagnoses  will  not  be  made  until  general 
practitioners  realize  the  great  value  of  an  educated  touch  as 
our  best  reliance  for  this  purpose,  and  insist  on  periodical 
examinations  of  all  women  over  forty  years  of  age. 

The  curative  employment  of  zinc-mercury  ions  is  necessarily 
confined  to  the  incipient  cases,  with  the  disease  limited  to  the 
cervix  alone.     Owing  to   the   insensitive  nature   of   this  por- 

199 


200  Applications  to  the  Cervix  Uteri. 

tion  of  the  organ  what  may  be  called  a  minor  application  is 
often  sufficient,  when  repeated  daily;  for  as  much  as  lOO  to 
150  milliamperes  may  be  used,  monopolar,  without  anesthesia, 
and  repeated  daily  until  sufficient  sterilization  has  occurred, 
or  intermitted  until  the  separation  of  the  slough  enables  the 
operator  to  judge  the  sufficiency  of  the  destruction  before 
starting  another  series. 

The  experience  indicated  below  shows  that  though  these 
methods  are  often  valuable  as  palliatives  in  advanced  cases, 
they  cannot  be  depended  on  to  materially  check  the  course  of 
the  disease  in  these  stages,  whether  employed  in  minor  or 
major  form. 

The  technic  of  the  minor  application  in  the  incipient  case  is 
as  follows :  With  the  patient  in  the  dorsal  position,  or  rarely 
in  the  Sims',  the  cervix  is  brought  into  view  by  means  of  a 
cylindrical  glass  speculum  and  the  slender,  pointed  electrode 
shown  at  D,  Fig.  15  (which  has  had  a  piece  of  Xo.  28  wire  at- 
tached to  the  blunt  end  and  been  insulated  with  fused  sealing 
wax  to  i^  cm.  of  the  tip,  the  latter  being  freshly  amal- 
gamated), is  inserted  into  the  diseased  part  parallel  with  the 
axis  of  the  cervix,  the  kaolin  pad  and  its  conducting  plate  is 
placed  on  the  abdomen,  or  under  the  back,  and  a  current  of  50 
to  150  milliamperes  is  turned  on  and  maintained  for  30 
minutes.  It  is  usually  necessary  to  hold  both  speculum  and 
electrode  in  place,  but  in  certain  cases  the  insertion  may  be 
made  by  touch,  without  the  speculum,  and  the  electrode  held  in 
position  by  a  tension  band  of  adhesive  plaster  attached  above 
the  pubes  and  to  the  buttocks,  passing  OA'er  the  outer  end  of 
the  electrode  and  holding  it  in  place  with  gentle  pressure  as  an 
arrow  is  held  in  the  bow. 

When  the  applications  are  made  with  the  glass  speculum,, 
which  is  the  preferable  technic,  the  field  of  application  may  be 
kept  under  continuous  brilliant  illumination  by  the  expedient 
of  placing  a  6-volt  miniature  lamp  inclosed  in  a  slender  glass 
tube  in  the  speculum,  lying  alongside  the  electrode,  thus  per- 
mitting an  accurate  visual  estimate  to  be  made  of  the  super- 
ficial extent  of  ionic  destruction. 

The  applications  are  repeated  daily  until  the  area  of  sterili- 
zation includes  the  whole  of  the  disease  and  the  immediately 
contiguous  parts  of  the  cervix,  or  until  from  four  to  six  appli- 
cations have  been  made,  when  they  should  be  intermitted  until 


Applications  to  the  Cervix  Uteri.  201 

such  time  as  the  slough  has  separated,  and  then  resumed  ac- 
cording to  indications.  By  this  method  about  five  or  more  ap- 
' .  plications  will  equal  in  desti^uctive  and  sterilizing  effect  an 
average  major  monopolar  application,  with  an  opportunity  af- 
forded to  avoid  undue  action  and  to  observe  the  results  be- 
tween treatments.  The  patient  should  be  kept  under  weekly 
observation  for  at  least  a  year,  and  the  applications  renewed  on 
the  appearance  of  suspicious  nodules  or  other  evidences  of  local 
disease  at  any  time  within  three  years. 

The  technic  of  palliative  applications  in  more  advanced 
cases,  in  which  extension  to  the  broad  ligaments  or  to  the 
glands  of  the  pelvis,  or  the  presence  of  metastasis,  renders  a 
cure  impossible,  is  exactly  similar,  except  that  a  blunt  electrode 
will  here  suffice  to  obtain  excellent  results  in  control  of  hemor- 
rhage, lessening  of  pain,  and  removal  or  lessening  of  odor. 

FIRST  SERIES. 

The  first  series  includes  10  cases,  of  which  8  were  inoper- 
able, 5  being  also  recurrent  after  cutting  or  curetting  opera- 
tions, and  2  operable. 

Of  the  inoperable  cases,  7  were  alleviated  and  i  died  of 
peritonitis  following  a  major  monopolar  operation.  There 
were  six  major  monopolar  operations  in  these  cases. 

Of  the  two  operable  cases,  in  both  of  which  minor  applica- 
tions alone  were  made  and  in  one  of  which  a  cure  was  ef- 
fected, a  full  account  is  appended. 

No.  6,  Private  Case  Book.  Incipient  Cancer  of  the  Cervix. 
— Mrs.  E.  A.,  aged  49,  was  first  seen  in  June,  1896,  with  an 
irregular,  deep  ulceration  of  the  cervix  with  proliferating  sur- 
face. The  late  Dr.  Theophilus  Parvin  saw  the  case  in  con- 
sultation and  agreed  in  the  diagnosis  of  squamous-celled 
epithelioma  on  the  microscopic  showing.  Treatment  was  by 
minor  applications  of  100  milliamperes  with  a  blunt  electrode, 
the  applications  having  a  duration  of  10  minutes  and  being  re- 
peated almost  daily  for  six  weeks,  when  the  patient  was  sent 
home  to  return  for  similar  applications  twice  a  month  for  six 
months.  At  the  end  of  the  course  of  treatment  mapped  out, 
which  was  carried  out  with  regularity,  there  was  no  evidence 
of  the  disease,  the  puckered  scar  being  quite  normal  in  appear- 
ance.    At  one  of  her  regular  visits   for  inspection  one  year 


202  Applications  to  the  Cervix  Uteri. 

later  she  was  again  seen  by  Dr.  Parvin  and  the  results  noted 
concurred  in. 

In  a  letter  dated  September  14,  1903,  Dr.  Chavanne,  of 
Salem,  N.  J.,  writes  that  the  patient  died  of  phthisis  pulmonalis 
about  seven  years  after  the  termination  of  the  treatment. 
There  was  no  recurrence  of  the  disease. 

No.  67,  Private  Case  Book.  Carcinoma  of  Cervix. — Mrs. 
J.  E.,  aged  57,  was  referred  by  Dr.  Franklin  D.  Castle  of 
Philadelphia,  November  7,  1903.  Family  history  negative. 
Five  years  before  she  had  been  treated  by  Dr.  Castle  for 
benign  uterine  trouble;  otherwise  the  personal  history  was 
good.  Four  months  ago  Dr.  C.  was  again  called  and  instituted 
local  palliative  treatment  for  a  condition  that  he  ultimately 
diagnosed  as  carcinoma. 

The  patient,  who  had  been  confined  to  her  bed  for  some 
time,  presented  the  appearance  of  good  health  save  for  pro- 
nounced anemia.  There  is  miicli  abdominal  and  pelvic  pain, 
with  dribbling  hemorrhage  and  offensive  discharge.  Exam- 
ination revealed  a  deep  ulceration  of  the  cervix  with  in- 
durated and  eroded  edges  which  bled  freely  on  touch,  the  end 
of  the  finger  being  readily  inserted  within  the  cavity  produced 
by  the  ulceration.     The  uterus  was  movable. 

As  the  patient  was  unable  to  leave  her  room,  a  suitable 
portable  apparatus  was  sent  to  the  house  and  proper  arrange- 
ments made  for  the  strongest  mercury  ion  applications  possible 
without  anesthesia.  On  November  7,  10  and  12  applications 
of  200  milliamperes  were  made  with  a  blunt  mercury-covered 
gold  anode  (34  cm.  by  2  cm.),  for  30  minutes'  duration,  the 
blunt  electrode  being  held  immovably  just  within  the  erosion. 
After  each  application  but  little  mercury  would  be  left  on  the 
gold  surface.  November  14  the  electrode  was  changed  to  a 
zinc-mercury  one  of  the  same  shape  and  dimensions,  as  suf- 
ficient destruction  had  not  been  secured,  and  from  100  to  150 
milliamperes  applied  as  before  for  30  minutes  on  this  date 
and  on  the  17th,  19th  and  21st.  On  the  24th  the  patient  was 
quite  weak  and  treatment  was  not  given.  On  December  7  a 
pear-shaped  slough,  round  and  hard,  was  lifted  out  of  a  cavity 
formed  by  the  outer  walls  of  the  supravaginal  cervix  and  the 
corpus,  leaxang  a  shelled-out  lower  segment  of  the  uterus  with 
apparently  healthy  edges.  No  bleeding  occurred  at  any  time 
after  the  beginning  of  the  treatment,  and  the  odor  ceased  after 


Applications  to  the  Cervix  Uteri.  203 

the  first  applications.  The  slough  was  shortly  after  shown  to 
the  Northern  Branch  of  the  Philadelphia  County  Medical 
Society. 

The  patient  was  kept  under  observation  for  two  years  and 
no  local  recurrence  was  noted,  though  she  complained  of  a  con- 
tinuance of  the  abdominal  pain  of  a  somewhat  vague  character. 
Her  condition  three  years  later  was  kindly  reported  to  the 
writer  by  her  physician,  Dr.  Henry  Beates,  Jr.,  in  a  letter  dated 
March  13,  1909,  as  one  of  "  carcinomatous  infiltration  of  the 
pelvic  tissues.  Her  sufiferings  are  sufficiently  intense  to  re- 
quire careful  analgesic  measures." 

It  will  be  noted  that  this  case  presented  the  unusual  symp- 
tom of  abdominal  pain  when  first  seen :  a  rare  phenomenon  in 
the  early  stages  of  carcinoma  of  the  cervix,  and  one  that  ren- 
ders the  prognosis  distinctly  gloomy. 

SECOND    SERIES. 

No.  35.  Oncologic  Hospital.  Carcinoma  of  Cervix. — 
Mrs.  Mary  Q.,  aged  53,  was  admitted  February  i,  1905.  She 
had  passed  the  menopause  two  years  before,  but  for  three 
months  has  had  a  slight  "  show "  every  two  weeks.  Two 
weeks  ago  she  had  a  severe  hemorrhage. 

Examination  shows  a  deep  ulceration  in  the  os,  with  ragged 
edges  distinctly  indurated  to  the  touch.  The  uterus  was 
movable  and  the  adnexse  apparently  healthy.  It  was  decided 
to  place  her  on  the  strongest  minor  applications  that  she  could 
bear,  push  the  method  until  the  affected  parts  were  included 
in  the  area  of  devitalization,  and  then  wait  for  the  separation 
of  the  devitalized  tissue  before  renewing  the  applications. 

February  4.  An  appropriate  electrode  was  selected  and  in- 
sulated to  2  cm.  from  the  tip.  With  the  cervix  exposed  by 
means  of  a  glass  cylindrical  speculum,  the  electrode  was  pain- 
lessly thrust  into  one  side  of  the  excavation  and  150  milliam- 
peres  turned  on  and  maintained  for  30  minutes.  This  pro- 
cedure was  repeated  February  6,  11,  24  and  28,  and  March  2 
and  8.  One  hundred  milliamperes  only  were  attained  March 
13,  16,  18,  23,  27  and  30,  when  a  rest  was  taken  on  account 
of  the  discharge  being  abundant.  April  6  she  received  80; 
April  II,  75;  April  15,  100;  April  24,  60;  April  27,  50.  The 
sloughing  was  now  free,  the  patient's  temperature,  respiration 
and  pulse  normal. 


204  Applications  to  the  Cervix  Uteri. 

May  12.  Examination  showing  excellent  edges  in  the 
wound,  no  application  is  made. 

May  15.  Final  application  of  25  milliamperes  and  dis- 
charge of  patient  to  the  dispensary,  with  urgent  injunction  to 
return  to  the  dispensary  at  intervals  of  one  week,  as  the 
probability  of  cure  was  great. 

June  8.  Forty  milliamperes  for  30  minutes  to  uncertain 
edge. 

The  patient  failed  to  return  after  July  and  was  not  seen 
until  September,  when  she  was  looked  up  at  her  home  and 
found  to  have  a  recurrence  of  the  disease. 

No.  162.  Oncologic  Hospital.  Inoperable  Carcinoma  of 
Cervix. — Mrs.  K.  M.,  aged  45,  was  admitted  June  24,  1905, 
with  an  extensive  carcinomatous  ulceration  of  the  cervix, 
which  had  extended  beyond  the  organ,  as  the  uterus  was  ad- 
herent on  the  left.  Palliative  minor  applications  with  a  blunt 
zinc-mercury  electrode  were  decided  on.  She  was  able  to 
take  200  milliamperes  for  30  minutes  on  the  following  dates: 
July  6;  August  i,  7  and  11 ;  September  5,  9  and  26;  and  Oc- 
tober 2,  6,  9,  20,  23  and  30. 

In  spite  of  decided  palliation  the  disease  remained  uncon- 
trolled, and  further  active  treatment  was  abandoned.  She 
died  March  5,  1906. 

No.  247.  Oncologic  Hospital.  Inoperable  Carcinoma  of 
Cervix  and  Vagina. — Mrs.  A.  C,  aged  37,  was  admitted  Oc- 
tober 20,  1905.  One  year  ago  she  suffered  a  miscarriage  at 
three  months;  a  month  after  recovery  her  menstruation  re- 
turned and  has  continued  as  a  dribble  since,  with  rare  periods 
of  relief.  Two  weeks  ago  she  was  admitted  to  the  Lancaster 
General  Hospital  at  Lancaster,  Pa.,  but  after  etherization  the 
surgeon  decided  not  to  operate. 

Examination  shows  a  large  growth  involving  the  mucous 
membrane  of  the  anterior  w^all  of  the  vagina  and  the  cervix, 
and  a  similar  growth  somewhat  smaller  in  the  posterior  wall 
of  the  vagina,  both  proliferant  and  of  a  whitish-red  color  on 
the  surface.  There  are  several  palpable  enlarged  glands  in 
the  groins.     Microscopic  examination :  carcinoma. 

Between  October  21,  1905,  and  April  11,  1906,  the  patient 
received  four  major  monopolar  applications  under  general  an- 
esthesia, each  of  300  to  400  milliamperes,  for  durations  vary- 
ing  from  20  to   30  minutes,   and   a  considerable  number   of 


Applications  to  the  Cervix  Uteri.  205 

minor  applications,  none  of  which  showed  Hnes  of  demarcation 
falHng  entirely  within  healthy  tissue. 

May  4,  1906.  The  results  attained  appearing  to  be  only  pal- 
liative, the  patient  was  referred  to  the  x-ray  department  of  the 
hospital  in  the  hope  that  more  could  be  done.  On  the  third 
of  June  she  returned  to  her  home  in  an  unimproved  condi- 
tion, and  notice  of  her  death  was  received  some  months  later. 

No.  425.  Oncologic  Hospital.  Carcinoma  of  Cervix 
Uteri. — ]\Irs.  S.  B.  K.,  aged  36,  was  admitted  April  11,  1907. 
Patient  had  been  under  treatment  for  uterine  trouble  of  un- 
certain character,  but  has  been  better  of  late  years.  Ten 
weeks  ago,  while  suffering  from  an  attack  of  influenza,  she 
had  a  uterine  hemorrhage,  which  has  continued  during  three 
out  of  four  weeks  since.  Has  pain  in  the  lumbar  regions  ana 
groins. 

Examination  shows  a  deep  ulceration  in  the  posterior  lip  of 
the  uterus,  with  indurated  edges.  The  uterus  was  freely 
movable.  A  specimen  removed  showed  the  disease  to  be  car- 
cinoma. 

During  April  five  minor  applications  were  made,  varying 
from  90  to  180  milliamperes  each,  for  durations  of  30  min- 
utes. On  the  20th  there  was  a  profuse  hemorrhage  in  con- 
nection with  the  separation  of  a  portion  of  dead  tissue,  con- 
trolled at  once  by  the  strongest  application  made.  On  the 
28th  a  normal  menstruation  interrupted  the  treatment. 

During  May  four  applications  were  made,  of  100,  160  and 
200  milliamperes,  varying  from  ten  to  thirty  minutes  in  dura- 
tion. On  the  1 6th  an  oval  slough,  resembling  inner  portion 
of  the  cervix,  was  removed  from  the  vagina. 

During  June  and  until  July  8  the  patient  received  ten  half- 
hour  applications  varying  from  50  to  75  milliamperes.  At  the 
latter  date  the  treatment  was  intermitted  as  the  parts  appeared 
to  be  healthy,  and  on  July  30  she  was  discharged  to  the  dis- 
pensary, where  she  received  two  applications  in  August  and 
one  in  September. 

January  4,  1908.  Patient  examined  and  parts  found  appar- 
ently free  from  disease.  Directed  to  return  twice  a  month 
for  examination. 

April  21,  1908.  Patient  has  received  five  applications  of  35 
to  90  milliamperes  since  last  entry,  as  the  posterior  lip  appeared 
to  be  uncertain  and  the  separation  of  a  slough  was  accompanied 


2o6  Applications  to  the  Cervix  Uteri. 

by  free  bleeding.  There  appears  to  be  no  disease  present  at 
this  time. 

June  24,  1909.  Examination  shows  no  sign  of  disease.  Pa- 
tient is  in  excellent  health. 

November,  1909.  Patient  still  under  observation  and  occa- 
sional prophylactic  treatment. 

No.  596.  Oncologic  Hospital.  Carcinoma  of  Cervix 
Uteri. — Mrs.  E.  C,  aged  61,  was  admitted  August  9,  1907, 
with  an  atrophied  uterus  and  eroded  cavity  in  the  os.  The  con- 
ditions had  been  present  but  two  months  according  to  the  pa- 
tient, and  somewhat  resembled  senile  endometritis,  though  the 
destruction  of  tissue  at  the  os  was  greater  than  usual  in  these 
cases.  The  patient  complained  of  moderate  pain.  A  speci- 
men removed  from  the  diseased  spot  was  pronounced  benign 
by  the  pathologist  of  the  hospital  some  time  later. 

November  23.  The  clinical  and  histologic  diagnoses  having 
conflicted,  the  patient  was  placed  on  minor  applications  of  zinc- 
mercury  ions,  75  to  35  milliamperes  for  30  minutes  each,  nine 
such  applications  having  been  made  between  the  date  of  ad- 
mission and  the  present.  The  patient  has  gained  six  pounds 
in  weight.  Treatment  intermitted  and  patient  kept  in  hospital 
under  observation. 

January  12,  1908.  Patient  has  recovered  from  an  attack  of 
la  grippe,  and,  under  examination  to-day,  is  apparently  free 
from  disease,  the  cervix  being  greatly  contracted  as  a  result  of 
lost  tissue.     On  the  25th  she  was  discharged  to  the  dispensary. 

February  10.  Minor  application  of  27  milliamperes  for  30 
minutes  to  doubtful  tissue  at  edge  of  cicatrix. 

February  24.  No  sign  of  disease  on  examination.  Patient 
seems  disappointed  at  cessation  of  treatment,  but  none  given 
in  view  of  the  excellence  of  the  local  conditions. 

March  31.  A  friend  informed  the  superintendent  of  the 
hospital  that  the  patient  felt  we  had  bothered  enough  with  her 
and  went  to  another  hospital  in  the  city,  where,  the  scars  being 
misinterpreted,  she  was  subjected  to  complete  hysterectomy, 
dying  the  same  day. 

No.  603.  Oncologic  Hospital.  Atrophic  Endometritis  {!). 
' — Mrs.  C,  aged  58,  was  admitted  from  Waco,  Texas, 
August  26,  1907.  For  one  and  a  half  years  she  had  com- 
plained of  a  persistent  leucorrhea,  with  some  lumbar  pain. 
The  menopause  had  been  passed  several  years  before. 


Applications  to  the  Cervix  Uteri.  207 

Examination  shows  uterus  decidedly  atrophied,  movable, 
with  normal  os,  but  exuding  bloody  mucus.  The  sound  and 
bi-manual  examination  revealed  atrophy  of  the  corpus  par- 
ticularly.    The  appendages  appear  normal. 

She  was  placed  under  zinc-mercury  intra-uterine  applica- 
tions with  a  bulbous  electrode  designed  to  fit  the  uterine  cavity, 
the  applications  being  of  ten  minutes'  duration  and  varying  in 
strength  from  50  to  90  milliamperes.  She  received  ten  appli- 
cations, and  was  sent  home  October  18  with  directions  for 
continuance  of  treatment  by  her  local  physician. 

July  12,  1908.  Letter  received  stating  that  the  uterine 
trouble  is  apparently  well, 

SUMMARY  OF  SECOND  SERIES  OF  UTERINE  CASES. 

Of  the  5  cases  reported  above,  excluding  the  case  of  atrophic 
endometritis,  2  were  inoperable  and  were  probably  little  bene- 
fited. Of  the  3  operable  cases  2  were  greatly  benefited  and 
would  possibly  have  been  cured  if  the  treatment  had  been  con- 
tinued; and  one  is  without  manifest  evidence  of  disease, 
though  still  under  close  observation. 


CHAPTER  XIV. 

APPLICATIONS    TO   THE    RECTAL   AND   ANAL   REGIONS. 

A  number  of  physical,  physiological,  and  surgical  reasons 
combine  to  render  zinc-mercury  ionization  peculiarly  adapted 
to  the  treatment  of  malignant  growths  in  the  anorectal  region. 
These  considerations  would  render  the  method  invaluable  even 
if  it  were  restricted  to  these  parts  alone. 

The  anorectal  region  is  more  than  usually  vascular,  hence 
the  bloodless  nature  of  the  operation  commends  it.  The  ease 
with  which  the  destructive  force  may  be  carried  by  insulated 
electrodes  to  a  point  high  within  the  rectum  enables  us  to 
destroy  a  growth  limited  to  these  parts  without  interference 
with  the  lower  sphincter.  No  large  vessels,  nerves,  or  serous 
cavities  are  encountered  in  the  region  that  may  not  be  safely 
destroyed  by  the  process,  hence  we  may  employ  the  method 
with  unusual  boldness.  And,  finally,  the  great  distance  of 
these  parts  from  the  vital  centers  enables  us  to  use  all  the 
current  needed  to  do  thorough  work,  the  reflex  stimulus  of 
such  large  currents  being,  in  fact,  an  element  of  safety  in  case 
the  patient  does  badly  under  the  anesthetic. 

An  important  physical  reason  also  is  the  fact  that  here,  as  in 
all  applications  within  cavities,  the  force  may  be  made  to  act 
from  within  outwards;  in  other  words,  the  peripheries  of  the 
growth  are  reached  by  currents  transmitted  from  electrodes 
thrust  radially  through  the  growth,  thus  reaching  the  growing 
edges  without  sacrifice  of  surrounding  normal  tissue.  This 
results  in  effectual  sterilization  of  the  diseased  parts  with  least 
loss  of  tissue,  the  inner  surface  of  normal  tissues  left  after 
separation  of  the  slough  being  healthy  throughout,  if  the  ap- 
plication has  been  thorough,  no  matter  how  extensive  and  ir- 
regular may  be  the  cavity  thus  made. 

This  cavity  is  painless,  and  contracts  ultimately  to  dimen- 
sions that  closely  resemble  the  normal  rectal  channel  or  anal 
outlet,  with  soft  edges,  covered  with  mucous  membrane  or 
skin.     When  final  contraction  has  occurred  normal  retention 

20S 


Applications  to  the  Rectal  and  Anal  Regions.         209 

usually  results,  except  with  liquid  stools,  with,  at  times,  some 
tendency  to  stricture. 


MAJOR   MONOPOLAR   APPLICATION. 

For  this  application  the  patient  should  be  placed  in  the 
lithotomy  position,  with  the  legs  well  elevated  by  leg  holders. 

If  the  operating  table  be  the  ordinary  metal  and  glass  one 
of  the  hospital  operating  room,  care  must  be  exercised  to  pad 
it  well  beneath  the  waterproof,  both  for  the  comfort  of  the 
patient  during  a  prolonged  treatment  and  to  permit  a  better 
adaptation  of  the  kaolin  pad  to  the  sides  of  the  trunk ;  and 
the  operator  or  head  nurse  should  see  that  the  arms  or  legs  do 
not  come  into  conducting  contact  with  the  metal  of  the  table 
or  leg  holders,  as  these  become  negatively  charged  frequently 
"by  stray  currents  and  are  liable  to  give  rise  to  burns.  This  is 
readily  obviated  by  covering  the  table  completely  with  the 
waterproof,  and  especially  by  wrapping  a  piece  of  rubber 
sheeting  or  insulating  tape  about  the  portion  of  the  leg  holders 
liable  to  come  into  contact  with  the  limbs. 

Two  pads  are  often  best  if  a  heavy  current  is  to  be  used,  so 
placed  that  the  edge  of  the  upper  one  is  even  with  the  shoul- 
ders. Between  the  pads  a  strip  of  rubber  sheeting  should  be 
laid  as  the  current  tends  to  seek  this  route  by  preference. 
After  the  patient  has  been  placed  in  position  a  deflated  Kelly 
pad  should  be  slipped  beneath  the  buttocks,  between  the  pa- 
tient and  the  pad,  to  deflect  the  return  current  to  the  more 
■distant  portions  of  the  surface  of  the  pad,  as  there  is  a 
tendency  to  short-circuit  at  this  spot,  with  damage  to  the  skin. 

With  the  patient  anesthetized  and  in  position,  and  the 
operator  seated  between  the  patient's  knees,  two  or  more  hard 
rubber  retractors  are  inserted  into  the  rectum  in  such  a  way 
as  to  bring  the  diseased  area  into  view  and  protect  the  healthy 
tissues,  the  retractors  being  held  by  nurses  after  being  placed 
in  position.  An  electrode  is  now  inserted  about  a  centimeter 
into  the  diseased  tissue  and  the  current  turned  on  gradually  by 
an  assistant. 

The  active  electrodes  are  made  of  zinc  1-32  inch  wide  and 
5  to  7  inches  long,  insulated  with  wax  throughout  their  ex- 
tent except  for  two  centimeters  from  the  tip.  Each  electrode 
is  attached  to  a  separate  piece  of  No.  32  wire  attached  in  com- 


2IO        Applications  to  the  Rectal  and  Anal  Regions. 

mon  to  the  positive  treatment  binding  post,  with  the  wire  so 
coiled  as  to  be  easily  handled  when  needed.  They  should  be 
amalgamated  immediately  before  use. 

Owing  to  the  small  active  surface  of  the  single  electrode  it 
is  often  difficult  to  get  more  than  200  milliamperes  into  the 
circuit  at  first,  polarization  occurring  rapidly,  so  a  second,  or 
even  a  third,  is  inserted  in  appropriate  spots.  In  spite  of  the 
use  of  several  points  a  current  of  400  milliamperes  confined 
to  the  growth  alone  will  shortly  develop  considerable  heat. 
When  this  is  shown  by  a  steaming  effect,  or  is  detected  by 
the  finger,  a  little  cold  water  should  be  carried  to  the  spot  by 
the  hard-rubber  tip  of  a  fountain  syringe,  but  the  water  should 
be  allowed  to  escape  at  once  as  soon  as  the  part  is  cool,  as  it 
otherwise  tends  to  convey  the  current  in  erratic  directions,  to 
be  turned  on  again  as  soon  as  the  temperature  again  becomes 
too  high. 

As  each  electrode  is  ascertained  by  inspection  to  have  ac- 
complished a  probable  sufficiency  of  action  at  its  particular 
point  of  insertion  it  is  removed  (the  remaining  electrodes  be- 
ing carefully  supported  in  their  position)  and  a  fresh  one  is 
inserted  in  a  new  spot,  until  all  diseased  tissue  shown  to  the 
eye  has  been  turned  to  a  grayish  white  color  and  devitalized 
to  a  sufficient  depth  to  reach  the  upward  and  lateral  extensions 
of  the  growth.  The  depth  and  amount  of  tissue  thus  devital- 
ized must  be  controlled  with  care  on  the  anterior  wall  of  the 
rectum,  to  avoid  in  male  patients  undue  inclusion  of  the 
prostate  and  in  women  the  recto-vaginal  septum,  otherwise  a 
free  destruction  should  be  made.  The  completeness  of  the  de- 
struction is  determined  from  time  to  time  by  visual  inspection 
or  by  the  sense  of  touch,  the  most  reliable  estimate  being  by 
the  tactiis  eruditus  of  the  educated  finger,  as  softening  of  the 
growth  accompanies  its  complete  ionization.  From  40  to  60 
minutes  of  actual  current  flow  will  usually  be  required. 

If  the  diseased  spot  be  high,  the  following  procedure  per- 
mits of  the  most  exact  placement  of  the  electrode :  Place  the 
point  of  the  electrode  against  the  palmar  surface  of  the  tip  of 
the  finger  and  insert  both  simultaneously  to  the  site  of  pro- 
posed puncture  by  touch;  with  the  point  of  the  electrode 
near  by,  locate  the  spot  accurately  by  touch  and  insert  the  elec- 
trode into  the  growth  guided  by  the  inserted  finger.  Hold- 
ing the  electrode  in  place  with  one  hand,  now  withdraw  the 


Applications  to  the  Rectal  and  Anal  Regions.         211 

inserted  finger  and  pass  the  speculum  up  over  the  conducting 
wire  and  electrode  into  the  rectum  until  the  site  of  the  in- 
serted portion  is  brought  into  view.  This  method  permits  an 
exact  placement  of  the  electrode  by  touch,  and  a  most  exact 
confinement  of  the  cataphoric  destruction  to  the  diseased  area ; 
it  makes  visual  examination  possible;  and  permits  of  ready 
cooling  of  the  parts  by  a  stream  of  water.  In  many  cases,  never- 
theless, the  speculum  is  unnecessary,  the  finger  remaining  near 
the  seat  of  action  to  note  increase  of  temperature,  which  is 
lowered  when  perceptibly  high  by  a  stream  of  cool  water  in- 
jected into  the  rectum  through  a  small  hard-rubber  tube  passed 
up  alongside  the  finger. 

After  Treatment. —The  parts  are  covered  with  a  simple 
perineal  pad  of  gauze.  The  burning  sensation  likely  to  be 
felt  by  the  patient  for  some  hours  after  emerging  from  the 
anesthetic  may  be  lessened  by  applying  pledgets  of  cotton 
saturated  with  witch-hazel,  or,  if  pain  is  complained  of,  a  dose 
of  morphine  should  be  given.  By  the  second  day  there  will 
usually  be  no  great  discomfort,  unless  distress  from  constipa- 
tion be  felt;  when  this  appears  a  hot  solution  of  sulphate  of 
magnesia  may  be  administered  by  mouth,  as  there  is  no  reason 
to  fear  any  ill  result  from  keeping  the  bowels  open,  if  the 
stools  be  liquid.  This  should  be  repeated  daily  until  the 
slough  comes  away,  which  occurs  between  the  twelfth  and  six- 
teenth days.  After  the  slough  separates  it  is  more  convenient 
and  comfortable  to  the. patient  to  permit  the  stools  to  be  solid. 

No  great  amount  of  after  discomfort  is  experienced  at  any 
time,  the  freedom  of  the  large  granulating  surface  from  ir- 
ritation due  to  fecal  movements  being  most  notable. 

The  usual  post-operative  inspections  should  be  made  at  short 
intervals  after  operations  in  this  region  as  the  growths  are 
likely  to  be  highly  malignant,  and  suspicious  nodules  should 
be  destroyed  promptly  by  a  minor  application. 

MAJOR     BIPOLAR     APPLICATION     TO     ANAL    REGION. 

The  bipolar  method  is  rarely  applicable  to  growths  within 
the  rectum,  but  is  usually  the  preferable  method  in  growths  in- 
volving the  whole  circumference  of  the  anus,  whether  extend- 
ing up  to  and  including  the  lower  third  of  the  rectum  or  not. 
The  position  of  the  patient  and  the  preliminary  preparations 


212        Applications  to  the  Rectal  and  Anal  Regions. 

are  the  same  as  that  described  above  for  the  monopolar  ap- 
plication, including  the  kaolin  pad  or  pads,  for  it  may  be  wise 
to  employ  the  latter  method  to  some  extent  at  the  end  of  the 
operation.  Instead  of  attaching  the  wire  from  the  plate  be- 
neath the  pad,  however,  the  wire  attached  to  the  bipolar  nega- 
tive electrode  is  attached  to  the  negative  binding  post  of  the 
apparatus,  the  ionizing  electrodes  being  inserted  well  beyond 
the  periphery.  This  rectal  bipolar  negative  electrode  is  best 
made  of  a  piece  of  thin  zinc  bent  into  the  shape  of  a  short 
cylinder  after  numerous  holes  have  been  punched  in  it,  the 
cylindrical  form  permitting  its  caliber  to  be  filled  with  gauze 
saturated  with  weak  sulphuric  acid  and  water  to  absorb  the 
hydrogen.  If  there  is  an  opening  in  the  center  of  the  growth, 
or  the  anus  is  still  patulous,  though  fully  diseased,  this  cylinder 
may  be  thrust  into  the  opening  and  be  self-retaining  during  the 
operation;  otherwise  it  should  be  held  in  place  against  the 
center  of  the  growth  during  the  application. 

Minor  Applicatioxs  to  the  Anorectal  Region. — The 
technic  of  the  minor  application  to  this  region  needs  no  ex- 
tended description,  the  chief  essentials  being  that  the  electrode 
be  as  light  and  fine-pointed  as  consistent  with  strength,  and 
that  all  but  the  active  point  be  carefully  insulated  with  sealing 
wax.  No  local  anesthetic  is  usually  needed  for  applications 
under  30  milliamperes  to  the  upper  portion  of  the  rectum,  but 
as  the  anal  region  is  extremely  sensitive,  subdermic  injections 
of  weak  Schleich  solution  are  best  at  this  point. 

An  Ionic  Kraske  Operation. — The  details  of  an  operation 
by  which  a  sarcoma  on  the  inner  surface  of  the  sacrum  was 
destroyed  by  ionic  electrodes  inserted  through  the  coccygeal 
tissues,  above  the  sphincter,  is  given  in  the  history  of  Case  66, 
in  which  a  large  sarcoma,  situated  within  the  pelvis  and  at- 
tached to  the  sacrum,  was  destroyed  by  two  heavy  current 
operations  without  interference  with  the  sphincter. 

FIRST  SERIES  OF  ANORECTAL   CASES. 

Nine  cases  of  anorectal  carcinoma  or  sarcoma  were  placed 
under  some  form  of  the  ionic  method  prior  to  1905,  four  being 
recurrent  after  excision  operations.  Of  these,  2,  reported  in 
full  below,  are  free  from  the  disease  at  the  present  time,  after 
the  expiration  of  six  and  five  years,  respectively;  2  w^ere  local 


Applications  to  the  Rectal  and  Anal  Regions.         213 

successes,  also  reported  below,  but  in  each  case  the  patient  died 
within  the  year  from  pre-operatively  implanted  metastasis, 
both  being  cachectic  when  first  seen;  4  cases  were  local  fail- 
ures (three  being  recurrent  at  the  time  of  operation)  ;  and  in 
one  case  the  ultimate  result  is  unknown,  though  the  immediate 
result  was  a  valuable  palliation  of  the  conditions  present.* 

Recurrent  Carcinoma  of  Rectum. — The  mother  of  a  physi- 
cian of  western  Pennsylvania,  aged  60,  was  first  seen  October 
26,  1901,  suffering  from  a  recurrent  carcinoma  in  the  ischio- 
rectal region.  The  original  growth  involved  a  portion  of  the 
sphincter  and  had  been  removed  by  a  Pittsburgh  surgeon  ten 
months  before  by  a  modified  Kraske  operation.  When  seen,  a 
sinus  was  found  to  the  left  of  the  anus  with  infiltrated  and 
indurated  edges,  communicating  with  a  cavity  about  two  inches 
in  depth,  the  whole  growth  being  about  the  size  of  a  lemon. 
The  rectal  mucous  membrane  was  intact  and  apparently 
healthy. 

At  the  application,  which  was  monopolar  and  made  under 
general  anesthesia,  the  cavity  was  filled  with  liquid  mercury, 
and  into  the  mercury  was  inserted  a  gold  tubular  electrode, 
amalgamated,  the  two  together  constituting  a  mercuric 
electrode  that  accurately  fitted  the  cavity  in  the  center  of  the 
growth.  A  current  increasing  from  400  to  650  milliamperes 
was  turned  on  and  maintained  for  i  hour  and  50  minutes. 
During  the  passage  of  the  current  the  induration  "  melted  " 
down,  the  progress  of  the  sterilization  being  determined  by  the 
progressive  disappearance  of  the  induration.  The  application 
was  well  borne,  destroyed  the  odor  of  the  discharge,  and  re- 
lieved the  pain.  After  the  separation  of  the  debris  the  cavity 
very  nearly  closed  by  granulation. 

Her  condition  six  weeks  later  was  greatly  improved;  but  it 
was  at  this  time  thought  best  to  make  another  application,  as 
a  part  of  the  wound  had  not  healed  and  was  suspicious. 

On  December  15  she  was,  therefore,  again  anesthetized  and 
the  process  repeated  with  from  200  to  300  milliamperes.  It 
was  only  necessary  to  keep  up  this  application  40  minutes. 

The  healing  was  complete  after  the  second  application,  and 
in  June,  1902,  her  son  reported  the  disease  apparently  cured, 
though  the  patient  was  weak  from  a  recent  attack  of  the  grip. 

*  For  full  report  of  some  of  these  earlier  cases,  vide  "  Conserv. 
Gyn.  &  Electro-Then,"  6th  edition,  page  247. 


214        Applications  to  the  Rectal  and  Anal  Regions. 

She  remained  in  reasonably  good  health  for  about  a  year,  when 
death  occurred,  probably  froH  ■■^•■. diastasis. 

Annular  Carcinoma  of  Upper  Rectum. — ]\Ir.  T.,  aged  44 
years,  was  brought  to  me  from  Campello,  a  suburb  of  Boston, 
Mass.,  August  i,  1902,  with  the  following  history:  He  had 
been  in  the  possession  of  excellent  health  until  about  nine 
months  before,  when  abdominal  trouble,  supposed  to  be  of  a 
dyspeptic  nature,  brought  him  under  the  care  of  his  family 
physician.  Xot  finding  rehef,  he  went  to  California  in  the 
spring  of  1902,  and  on  his  return,  in  April,  was  found  to  have 
lost  twenty-six  pounds  in  weight.  Obstruction  of  the  bowels 
finally  developed.  He  was  examined  by  Dr.  Cabot  of  Boston 
in  June,  and  carcinoma  of  the  rectum  was  clinically  diagnosed, 
the  diagnosis  being  confirmed  by  the  microscope. 

On  examination,  the  finger  encountered  a  firm  constriction 
about  five  inches  from  the  anus,  the  lumen  of  which  would 
not  admit  the  distal  phalanx.  The  constriction  was  cylindric, 
apparently  more  than  an  inch  long,  and  the  edges  were  ulcer- 
ated and  emitted  the  characteristic  odor  of  malignant  disease. 
For  some  time  the  ribbonlike  stools  had  been  replaced  by 
watery  discharges  only  under  the  action  of  salines.  The  pa- 
tient's color  was  good,  but  he  was  greatly  emaciated  and  suf- 
fered from  pain  in  the  left  groin. 

Notwithstanding  the  unfavorable  clinical  evidences  of  metas- 
tasis, the  patient  was  admitted  to  a  private  hospital,  and  on 
August  3  he  was  etherized  and  a  major  monopolar  applica- 
tion of  zinc-mercury  ionization  applied  as  described,  with  the 
assistance  of  Drs.  Hermance  and  Frank  White.  A  current  of 
500  milliamperes  was  gradually  attained  and  kept  up  for  69 
minutes,  exclusive  of  the  time  necessary  to  change  and  readjust 
the  electrodes.  At  the  end  of  this  time  all  portions  of  the 
growth  appeared  soft  to  the  finger,  and  examination  with  a 
lighted  proctoscope  showed  the  diseased  area  changed  to  a 
grayish  white. 

On  the  sixth  day  the  general  comfort  of  the  patient  was  dis- 
turbed by  a  rise  of  temperature  to  102  F.,  with  the  develop- 
ment of  localized  swelling  in  front  of  the  pubes  and  inability 
to  void  the  urine  naturally.  Both  of  these  symptoms  persisted 
for  several  days,  during  which  time  an  increasing  quantity  of 
debris  passed  from  the  rectum,  a  bedpanful  of  necrosed  tissue 
finally   passing   in   a   single   stool,    followed   by   normal    fecal 


Applications  to  the  Rectal  and  Anal  Regions.         215 

passages.     The  patient  went  home  at  the  end  of  three  weeks. 

On  September  22  I  exami  ■  '  *he  patient  and  found  the 
parts  healed,  soft,  normal  mucous  membrane  covering  the 
site  of  the  growth,  but  there  was  apparently  a  valvular  con- 
striction produced  by  scar  tissue  on  the  anterior  aspect.  The 
evidences  of  general  metastasis  still  persisted,  showing  that  the 
excellent  local  result  had  probably  been  attained  too  late  for  an 
actual  cure. 

The  general  ill  health  continued  after  the  patient  returned 
to  his  home,  resulting  in  death  at  the  end  of  about  six  months, 
without  recurrence  of  the  disease  in  the  rectum. 

Sarcoma  of  the  Sacrum. — Mrs.  C.  A.,  aged  26,  of  Royers- 
ford.  Pa.,  applied  for  treatment  October  i,  1903,  with  a  hard 
tumor  nearly  filling  the  pelvis,  examination  by  the  vagina  and 
rectum  showing  it  firmly  attached  in  its  whole  extent  to  the 
inner  wall  of  the  sacrum. 

She  had  had  two  confinements,  which  were  terminated  by 
instrumental  delivery,  both  children  dying  in  childbirth,  and 
a  more  recent  confinement  terminating  seventeen  months  be- 
fore being  seen,  in  which  the  child  was  delivered  normally, 
without  instruments,  and  was  still  living.  The  tumor  was  not 
discovered  until  March,  1903,  when  the  baby  was  11  months 
old. 

The  progress  of  the  growth  was  noted  by  her  physician  for 
several  months,  and  she  was  finally  sent  to  a  Philadelphia 
hospital,  where  an  opening  was  made  in  the  median  line  of 
the  abdomen.  The  true  nature  of  the  growth  was  then  dis- 
covered by  the  surgeon,  and  the  wound  was  closed  without 
effort  at  removal  of  the  growth,  which  was  pronounced  in- 
operable. This  was  in  September,  three  weeks  before  coming 
under  the  author's  observation.  After  leaving  the  hospital  she 
was  sent  by  her  former  medical  attendant,  Dr.  James  C. 
Mewhinney  of  Royersford,  to  Dr.  W.  W.  Keen  of  Philadel- 
phia, who  concurred  in  the  diagnosis  of  sarcoma  of  the  sacrum. 
and  stated  that  an  operation  would  probably  be  fatal,  and 
surely  result  in  paralysis. 

The  patient's  general  condition  was  subnormal,  she  being 
anemic,  thinner  than  usual,  and  beginning  to  suffer  from 
stricture  of  the  rectum.  An  attempt  to  destroy  the  growth 
was,  nevertheless,  determined  upon. 

October  5,  1903,  a  major  monopolar  application  was  made, 


2i6        Applications  to  the  Rectal  and  Anal  Regions. 

with  the  kind  assistance  of  Dr.  J.  E.  Porter  of  Pottstown,  and 
in  the  presence  of  Dr.  Mewhinney.  The  patient  was  placed 
with  her  right  side  resting  on  a  large  pad,  a  portion  of  which 
extended  up  the  back  between  the  shoulders  and  in  front  on 
the  abdomen,  as  a  large  current  was  evidently  needed.  It  was 
decided  to  make  an  opening  through  the  unaffected  skin  above 
the  anus  with  the  ionic  action  itself,  with  a  view  to  saving 


Fig.  69. — Diagram  of  median  section  of  pelvis  showing  sarcoma  of 
sacrum.  The  portion  of  the  tumor  destroyed  by  the  first  operation 
is  inclosed  by  a  broken  line,  and  includes  the  last  three  bones  of  the 
coccyx.  The  remainder  of  the  growth,  including  the  first  segment 
of  the  coccyx,  was  destroyed  by  the  second  operation,  and  is  indi- 
cated by  a  dotted  line. 

the  anus  and  sphincter,  the  formation  of  a  channel  through 
the  skin,  coccyx,  and  lower  end  of  the  sacrum  by  the  electric 
action  avoiding  all  opening  of  vessels.  A  slit  was  accordingly 
made  in  the  skin,  and  a  large,  stout,  amalgamated  zinc  electrode 
with  sharp  point  was  thrust  into  the  tumor  with  a  finger  in  the 
rectum  as  guide,  grazing  the  apparently  softened  coccyx. 
This  instrument  was  uninsulated,  the  purpose  being  to  make 
a  wide  opening  for  the  subsequent  passage  of  the  devitalized 


Applications  to  the  Rectal  and  Anal  Regions.         217 

tissue.  A  strength  of  1000  milliamperes  was  shortly  reached, 
when,  the  necrosis  extending  and  showing  signs  of  heating,, 
three  other  more  slender  electrodes,  each  about  7  inches 
long,  were  inserted  alongside  the  first  to  a  total  depth  of  4)^2 
inches.  The  current  was  then  raised  to  1600  milliamperes,. 
which  was  maintained  for  3  hours,  being  lowered  somewhat 
during  the  last  hour. 

The  application  was  well  borne.  At  its  expiration  three 
burns  were  found  at  different  points  under  the  negative  plate,, 
due  to  this  plate  being  too  stiff"  to  adapt  itself  properly  to  the 
contour  of  the  body.  These  skin  necroses  gave  the  patient 
more  subsequent  discomfort  than  the  wound  proper,  but 
ultimately  were  covered  with  soft  cicatrices.* 

Aside  from  theaccidental  necroses  of  the  skin,  the  after- 
condition  of  the  patient  was  comparatively  comfortable,  the 
skin  and  three  segments  of  the  coccyx  coming  away  in  six- 
teen days,  and  a  large  portion  of  the  tumor,  a  piece  about  the 
size  of  a  fist,  shown  on  a  reduced  scale  in  Fig.  70,  coming 
away  on  the  twentieth  day,  with  a  sharp  hemorrhage,  readily 
controlled  by  pressure. 

After  the  separation  of  the  slough,  which,  by  the  way,  was 
practically  inodorous,  having  been  dressed  with  carbolized  zinc 
oxide  powder,  the  conditions  were  as  follows :  There  was  an 
opening  about  three  inches  in  diameter  extending  into  the 
rectum,  the  lower  edge  being  ijA  inches  from  the  intact  anus. 
At  the  bottom  of  this  opening,  which  was  2  inches  deep,  the 
red  tissue  of  about  one-half  of  the  tumor  was  visible  (Fig.  69). 
That  this  was  a  portion  of  the  tumor  was  clearly  shown  by 
vaginal  and  rectal  examination,  the  finger  now  being  able  to  be 
hooked  over  its  upper  border. 

On  November  2  a  second  major  monopolar  application  was 
made  through  the  opening,  with  long  electrodes  so  insulated 
as  to  protect  the  healthy  edges  of  the  opening.  A  current  of 
1600  milliamperes,  later  decreased  to  800,  was  employed  for 
1%  hours,  with  four  electrodes.  Careful  attention  to  the 
dispersing  pad  prevented  accidents  in  this  situation  at  this 
time. 

The  devitalized  tumor,  about  the  size  of  a  large  fist,  came 

*  Since  the  date  of  treatment  of  this  patient  the  negative  pad  has 
been  changed  from  a  cotton  compress  to  a  kaolin  pad,  resulting  in 
an  entire  elimination  of  burns  of  this  character. 


2i8        Applicotions  to  the  Rectal  and  Anal  Regions. 

away  cleanly  without  a  drop  of  blood,  in  seventeen  days,  leav- 
ing, fortunately,  no  sign  of  remnants  in  its  former  situation. 
Examination  through  the  wound  showed  the  lower  third  of 
the  sacrum  roughened  on  its  inner  wall,  and  the  devitalized 


Fig.  70. — The  two  pieces  of  sarcoma  tissue 
and  the  segments  of  the  coccyx,  as  they 
appeared  after  separation  (reduced  to  one- 
fourth   size). 

first  segment  of  the  coccyx  was  picked  out  of  the  wound  pain- 
lessly two  weeks  later  (Fig.  70). 

During  December  efforts  were  made  to  direct  the  fecal  dis- 
charges through  the  natural  anal  opening,  all  discharges  hav- 
ing thus  far  passed  through  the  operative  opening  owing  to 
the  destruction  of  the  posterior  rectal  wall.  Several  hard  rub- 
ber tubes  of  various  sizes  and  curves  were  inserted  into  the 
rectum  through  the  anus,  but  all  failed  of  their  purpose  and 
were  finally  abandoned,  the  fecal  discharges  continuing  to  pass 
through  the  wound  until  its  gradual  narrowing,  late  in  the 
winter,  diverted  the  feces  into  the  natural  channel  through  the 
anus. 

The  patient  sat  up  the  second  week  of  December,  went 
downstairs  on  Christmas  Day,  and  walked  out  January  10. 
On  January  13  she  had  the  first  natural  movement  through 
the  anus.  " 


Applications  to  the  Rectal  and  Anal  Regions.         219 


Fig.    71. — Photograph   of   scar   six   years    after   ionic    destruction    of 
sarcoma  of  sacrum. 

At  the  present  time,  November,  1909,  six  years  after  the 
last  application,  the  patient  is  in  unusually  good  health,  with 
no  evidence  of  fullness  or  growth  of  any  kind  in  the  pelvis 


220        Applications  to  the  Rectal  and  Anal  Regions. 

or  elsewhere.  She  walks  and  sits  easily,  and  the  opening- 
shown  in  the  photograph  (Fig.  71)  has  long  since  entirely 
closed. 

At  the  time  of  the  second  application  a  small  portion  of  the 
growth  was  removed  and  sent  to  the  Philadelphia  Clinical 
Laboratory  for  histologic  examination.  The  report  character- 
ized the  growth  as  a  fibromyxosarcoma. 

Epithelioma  of  the  Rectum. — Mrs.  J.  H.,  aged  57,  was  re- 
ferred by  Dr.  H.  R.  Swayne,  May  4,  1904.  In  1902  she  was 
operated  on  by  excision  for  cancer  of  the  uterus,  in  its  early 
stages,  and  an  apparent  cure  effected.  For  some  time  she 
has  had  a  sensation  of  a  foreign  body  in  the  rectum,  more  re- 
cently accompanied  by  pain,  and  Dr.  S.  discovered  the  growth 
and  secured  the  diagnosis  of  epithelioma  from  the  private 
laboratory  of  Dr.  Boardman  Reed. 

Examination  showed  a  growth  on  the  posterior  wall  of  the 
rectum  about  3  inches  above  the  anus ;  it  had  a  raised,  prolifer- 
ating surface. 

May  4,  1904.  Major  monopolar  operation,  with  the  as- 
sistance of  Dr.  Swayne.  Under  general  anesthesia  a  spear- 
shaped  electrode  was  prepared  with  a  proper  curve,  inserted 
through  the  anus  into  the  growth,  and  500  milliamperes  turned 
on  and  maintained  for  60  minutes,  inclusive  of  frequent  turn- 
ing off  of  the  current  for  inspection  of  the  parts,  the  rectum 
being  kept  cool  by  frequent  irrigation  of  the  site  of  applica- 
tion by  cool  water  carried  to  the  spot  by  a  hard  rubber  tube. 
There  was  considerable  secondary  hemorrhage  on  the  four- 
teenth day,  on  the  separation  of  the  slough,  readily  controlled 
by  an  injection  of  Monsell's  Solution  in  glycerine  in  the  pro- 
portion of  2  parts  of  the  solution  to  6  of  glycerine. 

The  patient's  general  condition,  which  had  been  poor,  gradu- 
ally improved,  while  the  rectum  retained  its  functions  in  full, 
save  for  a  tendency  to  constipation  during  the  first  year,  due 
to  the  rectal  tube  being  bent  sharply  on  itself  at  the  site  of 
the  scar,  its  posterior  wall  being  attached  to  the  sacrum. 

At  the  present  writing,  five  and  a  half  years  after  the 
operation,  the  patient  is  in  excellent  health  and  without  any 
sign  of  a  recurrence.  The  contracted  spot  at  the  site  of  the 
scar  seems  to  be  looser,  the  index  finger  entering  the  lumen  of 
the  stricture  more  readily,  and  there  seems  to  be  no  difficulty  in 
defecation. 


Applications  to  the  Rectal  and  Anal  Regions.         221 

SECOND    SERIES    OF    ANORECTAL    CASES. 

No.  2^2.  Oncologic  Hospital.  Recurrent  Carcinoma  of 
Rectum. — Mrs.  C.  A.,  aged  46,  was  referred  by  Dr.  T.  L. 
Adams  of  Philadelphia,  December  13,  1906.  Five  years  ago 
she  was  operated  on  by  a  gynecologist  for  "  tumors  on  the 
uterus"  (real  condition  unknown).  Six  months  ago  first  no- 
ticed trouble  with  the  rectum,  mainly  pain  that  prevented 
sleep.  Eight  weeks  ago  Dr.  Adams  found  a  lump  at  the  edge 
of  the  anus  the  size  of  a  lima  bean,  and  operated  on  it  by 
the  knife  and  cautery. 

Examination  shows  a  proliferating  growth  about  3  inches  in 
diameter  surrounding  anus  and  extending  about  2  inches  up 
the  rectum,  ulcerated  and  breaking  down.  The  patient  com- 
plains of  pain  in  the  anus,  buttocks,  and  within  the  abdomen, 
and  has  lost  flesh  of  late. 

On  the  14th  a  major  monopolar  application  was  made  under 
ether,  1000  milliamperes  being  applied  for  80  minutes,  with 
six  electrodes  thrust  just  beyond  the  periphery  of  the  growth 
to  a  depth  of  2  inches,  parallel  with  the  rectal  walls.  The 
patient  was  unable  to  void  urine  voluntarily  for  ten  days,  but 
the  bowel  movements  were  unimpaired.  On  the  27th  and  30th 
large  sloughs  separated,  leaving  an  apparently  healthy  wound, 
though  six  minor  applications  were  made  during  the  following 
two  months  to  doubtful  granulations,  the  patient  being  dis- 
charged from  the  hospital  February  10. 

The  patient's  general  health  had  remained  poor  in  the 
hospital,  with  poor  appetite,  sleeplessness,  and  pain  within  the 
abdomen.  These  conditions  grew  worse  after  her  return 
home,  aggravated  by  recurrence  of  the  disease  in  the  edge  of 
the  wound,  and  she  died  of  metastatic  growths  and  general  in- 
anition several  months  later. 

No.  616.  Oncologic  Hospital.  Fihro-Sarcoma,  Round- 
Celled,  of  Rectum. — T.  H.,  aged  64,  farrtter,  was  referred  by 
Dr.  E.  L.  Moodie  of  Chatham,  Ohio,  April  25,  1906.  His 
mother  died  of  cancer  of  the  face.  Without  previous  history 
of  hemorrhoids  or  other  ill  health,  he  noticed  bleeding  at  stool 
about  two  years  ago  and  later  stools  made  up  of  blood  alone. 
About  nine  months  ago  he  began  to  have  watery  discharges 
from  the  rectum,  with  much  odor. 

Examination   shows   a  large  growth   within   lower   rectum. 


222        Applications  to  the  Rectal  and  Anal  Regions. 

• 
the  lowest  point  being  two  inches  above  anus.     Its  greatest 

thickness  is  posterior,  with  extension  to  either  side  to  near 

neighborhood    of    prostate.     The    bowels    have    refused    to 

move  lately  in  spite  of  saline  cathartics. 

April  26,  1906.  Major  monopolar  application  under  chloro- 
form, 1400  to  1600  ma.  for  one  hour,  with  insulated  electrodes, 
the  anus  being  retracted  by  hard  rubber  retractors. 

April  27.  Patient  had  free  movements  of  the  bowels  dur- 
ing the  night  following  operation.  Temperature  and  pulse  nor- 
mal.    Irrigation  with  weak  permanganate  solution. 

May  13.     Small  portion  of  slough  came  away  bloodlessly. 

May  19.  Digital  examination  showing  the  presence  of  un- 
destroyed  disease,  minor  applications  to  patient's  endurance 
were  begun. 

December  23.  Patient  has  remained  in  hospital  under  minor 
apphcations,  thirty  in  all,  of  50  to  300  ma.  for  half-hour 
each,  with  great  alleviation  of  the  local  condition,  but  with-, 
out  entirely  arresting  it.  Evidence  of  metastasis  to  other 
structures,  with  cachexia,  are  now  so  marked  that  further 
active  treatment  is  abandoned  and  general  treatment  alone 
continued. 

January  22.  Left  hip  enlarged  and  painful ;  evidently  a 
metastatic  deposit. 

January  26,  1907.     Patient  died  of  inanition. 

No.  740.  Oncologic  Hospital.  Carcinoma  of  Rectum. — 
Mr.  K.,  aged  63,  was  referred  by  Dr.  F.  H.  Morse  of  Boston, 
Mass.,  April  25,  1908.  Thirteen  months  ago  the  patient  be- 
gan to  have  bloody  discharges  from  the  rectum,  mixed  with 
mucus,  and  eight  months  ago  pain  appeared  and  has  grown 
worse  to  the  present  time.  During  this  period  constipation 
has  increased  until  at  present  only  powerful  saline  cathartics 
can  induce  movement.  The  patient  is  normally  sallow,  but  of 
late  is  much  more  anemic  and  probably  cachectic. 

Examination  of  ^he  rectum  by  touch  reveals  a  growth  2 
inches  from  the  anus  consisting  of  an  annular  proliferation 
surrounding  the  rectal  caliber  and  of  a  total  dimension  equal 
to  a  small  hen's  egg.  The  inner  surface  of  the  growth  was 
eroded,  bled  easily,  and  gave  rise  to  a  foul  discharge.  The 
growth  was  movable,  with  apparently  no  attachment  to  the 
pelvic  wall.  Its  caliber  would  not  admit  the  tip  of  the  finger. 
Microscopic  examination  showed  it  to  be  a  carcinoma.     Blood 


Applications  to  the  Rectal  and  Anal  Regions.         227, 

count:  erythrocytes  3,880,000;  leucocytes  11,760,  hemoglobin 
72  per  cent. 

April  25,  1908.  Major  monopolar  application  under  general 
anesthesia,  400  to  600  milliamperes  for  35  minutes.  The 
operation  was  followed  by  greater  freedom  of  movement  of 
the  bowels,  but  the  catheter  had  to  be  used  to  empty  the  blad- 
der for  nine  days,  after  which  the  urine  was  readily  voided. 
The  separation  of  the  slough  was  unaccompanied  by  henior- 
rhage. 

May  13.  Examination  by  touch  shows  an  open  tube  at  site 
of  tumor  admitting  the  finger  readily,  with  soft  folds  of 
mucous  membrane  at  edges.  Patient  now  has  formed-  move- 
ments showing  mucus  of  obviously  higher  origin  than  rectum 
and  indicating  an  old  mucous  enteritis.  Orphol  (Beta-Naph- 
thol-Bismuth)  powders  prescribed. 

June  9.  Stools  normal  and'  condition  greatly  improved. 
The  site  of  disease  is  occupied  by  a  stricture  with  normal  edges 
3^  inches  above  anus. 

July  21.  Proctoscopic  examination  in  consultation  with  Dr. 
Codman  confirms  healthy  condition  of  stricture.  Dilatation 
begun  by  No.  15  dilating  urethral  catheter. 

August  20.  Patient  referred  back  to  Dr.  Morse  for  further 
treatment  of  the  stricture.  There  is  no  sign  of  recurrence  of 
the  disease. 

No.  810.  Oncologic  Hospital.  Carcinoma  of  Rectum, 
Recurrent. — Steamboat  captain,  aged  49,  was  referred  by  Dr. 
W.  T.  Roberts  of  Louisville,  Ky.*,  September  17,  1908.  Per- 
sonal and  family  history  good,  except  for  an  old  malarial  in- 
fection received  during  a  residence  in  Arkansas  years  ago.  It 
is  possibly  due  to  this  that  the  patient's  color  is  unusually 
swarthy.  Three  years  ago  he  had  a  sudden,  painless  hemor- 
rhage from  the  rectum,  and  one  year  later  a  constant  inclina- 
tion to  stool  was  noticed.  December  6,  1906,  he  entered  a  hos- 
pital in  Louisville  and  was  operated  on  by  excision,  the  anus. 
and  about  4  inches  of  the  rectum  being  removed.  There  was 
an  improvement  in  the  general  health,  but  two  small  nodules 
of  recurrence  were  noticed  at  the  edge  of  the  anus  as  soon  as 
healing  occurred.  His  condition  became  very  bad  five  months 
ago.  During  the  last  twenty  days  there  has  been  no  move- 
ment of  the  bowels. 

Examination   showed   a  mass   protruding   from   the   rectal 


224        Applications  to  the  Rectal  and  Anal  Regions. 

opening  3  by  2  cm.,  being  an  outward  extension  of  an  in- 
durated, nodular  mass  that  encircles  the  anus  and  extends 
about  4  inches  up  the  rectum.  The  index  finger  could  be  in- 
serted but  3  inches,  encountering  indurated  walls,  which  were 
narrowest  at  the  upper  portion  of  the  growth.  Anteriorly  the 
growth  appeared  to  be  adherent  to  the  prostate.  Blood  count : 
erythrocytes  4,200,000;  leucocytes  10,200;  hem.  70  per  cent. 
Microscopic  examination :  carcinoma. 

September  9,  1908.  With  a  prognosis  that  included  recog- 
nition of  the  probability  of  metastasis,  and  of  the  probability 
of  failing  to  eradicate  the  disease  next  to  the  prostate  (the 
patient  stipulating  that  the  bladder  was  not  to  be  opened  by 
the  ionic  process),  a  major  bipolar  application  was  made  on 
this  date,  800  to  2000  milliamperes  being  used  for  40  minutes, 
according  to  the  technic  described  on  page  211,  with  a  cylin- 
dric  negative  thrust  into  the  cavity  and  6  electrodes  in- 
serted at  one  time  just  beyond  the  periphery  of  the  growth 
to  a  depth  of  4  inches,  avoiding  the  region  of  the  prostate. 
Within  tw^o  hours  after  being  put  to  bed  the  bowels  moved 
freely,  and  during  the  night  there  were  seven  large  move- 
ments without  discomfort.  Difficulty  in  voiding  urine  was 
complained  of  for  ten  days,  and  a  large  slough  was  passed 
with  the  feces  on  the  twelfth  day. 

January  6,  1909.  There  are  symptoms  of  failure  to  erad- 
icate the  disease  on  the  left  side  of  the  anal  opening,  and  the 
prostatic  region  still  continues  doubtful.  Second  major  oper- 
ation under  anesthesia,  the  application  this  time  being  mono- 
polar as  there  is  but  little  doubtful  tissue  to  be  destroyed, 
400  to  500  milliamperes  for  40  minutes,  6  electrodes. 

February  27.  Patient  allowed  to  go  home,  as  all  portions  of 
the  periphery  of  the  rectum  present  a  normal,  healthy  scar, 
soft  and  pink,  except  the  uncertain  prostatic  region,  several 
colleagues  feeling  confident  that  there  is  no  disease.  Directed 
to  return  in  ninety  days. 

April  25.  Patient  returns  to  hospital  at  suggestion  of  Dr. 
Roberts,  having  had  no  fecal  movement  for  four  days.  Ex- 
amination shows  an  indurated,  shell-shaped  excavation  on  the 
prostatic  side  of  the  anal  opening,  probably  containing 
malignant  structure ;  at  the  depth  of  2  inches  this  ends  in  a 
constriction  through  which  the  tip  of  the  forefinger  may  be 
inserted,  but  which  is  filled  with  prolapsed  bowel,  like  a  ball 


Applications  to  the  Rectal  and  Anal  Regions.        225 

valve.  A  soft  rubber  tube  was  inserted  through  the  constric- 
tion through  which  fecal  movements  were  secured  for  a  time. 
Minor  applications  were  made  to  the  malignant  growth  in  the 
prostate  ineffectually,  and  were  finally  abandoned,  the  patient 
dying  from  extension  of  the  disease  June  19. 

No,  999.  Oncologic  Hospital.  Recurrent  Adenocar- 
cinoma of  Rectum. — Mrs.  Y.,  aged  69,  was  referred  by  Dr. 
Mary  Dunning  of  Newburgh,  N.  Y.,  September  3,  1909.  She 
had  what  was  supposed  to  be  hemorrhoids  for  four  years. 
March  22  last  a  growth  diagnosed  microscopically  as  adeno- 
carcinoma was  removed  by  excision,  including  the  greater  por- 
tion of  the  lower  rectal  wall.  One  week  ago  Dr.  Dunning 
discovered  a  recurrence. 

Examination  discloses  six  nodules  about  the  size  of  marbles 
in  the  line  of  the  incision  3  inches  above  the  anus,  with  a 
continuous  indurated  mass  at  the  anal  edge.  The  growths  are 
ulcerated  and  proliferant. 

September  6,  1909.  Major  monopolar  application  under 
ether,  400  to  900  milliamperes  for  T^y  minutes,  8  needles  being 
inserted. 

October  12.  Examination  to-day  shows  no  evidence  of 
disease  in  rectal  wall  or  anal  edges,  both  of  which  appear  soft 
and  covered  with  normal  tissue.  The  anus  appears  "par- 
ticularly normal  in  its  new  covering  of  scar  tissue,  the  sphinc- 
ter being  apparently  perfect.  One  and  a  half  inches  above 
the  anus  there  is  an  opening  between  the  bowel  and  vagina 
admitting  the  thumb,  through  which  most  of  the  feces  pass. 

November  i.  No  evidence  of  recurrence  shown  to-day. 
The  anus  appears  normal,  but  feces  still  pass  through  the  recto- 
vaginal fistula,  which  has  contracted  somewhat. 

SUMMARY   OF   NEW    SERIES   OF   RECTAL   CASES. 

Of  the  five  cases  treated  since  1905,  2  cases  are  without 
manifest  evidence  of  disease  at  present,  and  3  were  failures. 


CHAPTER  XV. 

MISCELLANEOUS  CASES  OF  MALIGNANT  DISEASE  IN  WHICH  ZINC- 
MERCURY  IONIZATION   WAS  USED. 

Lymphoma  of  Neck. — Mrs.  F.  J.  F.,  aged  26,  applied  for 
treatment  May  15,  1903.  A  tumor  in  the  riglit  side  of  ttie 
neck  was  first  noticed  three  years  ago.  It  grew  rapidly  while 
she  was  pregnant  with  her  first  child,  now  five  months  old. 

The  tumor  is  situated  in  the  neck  below  the  left  jaw.  It 
is  ovoid  in  shape,  measuring  3^   by  2  inches    (8  by  5  cm.) 


Fig.  72. — Lymphoma  of  neck. 

deeply  situated  beneath  the  skin,  and  painless.  (See  photo- 
graph. Fig.  72.) 

Believing  the  growth  to  be  probably  tubercular,  minor  ap- 
plications of  10  to  15  milliamperes  were  made  through  a  sinus 
produced  by  the  first  application.  This  was  persisted  in  for 
several  months,  without  materially  reducing  the  size  and  di- 
mensions of  the  shell  of  the  growth,  in  spite  of  the  center 
being  favorably  changed. 

March  9,  1904.  Patient  returns  with  tumor  slightly  larger 
than  when  first  seen,  causing  the  formation  of  a  clinical  diag- 
nosis  of   malignancy.     A   major  monopolar   application   was 

226 


Zinc-Mercury  Ionization  in  Miscellaneous  Cases.       227 

made  at  this  date  at  the  patient's  residence,  assisted  by  Dr.  Her- 
mance,  350  to  400  milhamperes  being  employed,  with  6 
needles,  for  40  minutes. 

After  the  separation  of  the  slough  minor  applications  of  40, 
25  and  15  milhamperes  were  made  during  the  following  month. 

At  the  present  time,  five  and  a  half  years  later,  the  patient  is 


Fig.  73-— Photograph  of  patient  shown  in  Fig.  72  four  years 
after  ionic  operation. 


well  and  shows  no  sign  of  recurrence.  The  second  photograph 
(Fig-  73)  was  taken   August  14,  1908. 

Sarcoma  of  Neck.  (No.  320,  Oncologic  Hospital).— 
Wm.  R.,  aged  47,  was  admitted  to  Dr.  McClary's  service  March 
6,  1906.  The  patient  came  to  the  hospital  from  the  Home  for 
Incurables,  where  he  had  been  admitted  as  an  incurable  patient. 
The  greater  portion  of  the  left  side  of  the  neck  was  the  site 
of  a  proliferating,  ulcerated,  foul-smelling  growth  (Fig.  74) 
that  apparently  extended  deeply  into  the  tissues  of  the  neck. 
Microscopic  examination :  sarcoma. 

Dr.   McClary  made  fourteen  injections  of  Trypsin,  in  ac- 


228       Ziuc-Mcrcur\  Ionization  in  Miscellaneous  Cases. 


Fig.  74. — Sarcoma  of  neck.     Case  320. 


Fig.  75. — Appearance  of  scar  of  case  shown  in  Fig.  74  three  and  a  half 
years  after  ionic  destruction  of  sarcoma. 


Zinc-Mercury  Ionization  in  Miscellaneous  Cases.       229 


Fig.  76. — Sarcoma  of  arm.     Case  474. 


Fig.  77. — Scar  of  sarcoma  of  arm  shown  in  Fig.  76 
as  it  appears  three  years  after  treatment. 


cordance  with  the  Beard  method,  and,  as  the  growth  was  not 
affected  in  any  way,  referred  the  case  to  the  author  for  an 
ionic  appHcation. 


230       Zinc-Mercury  Ionization  in  Miscellaneous  Cases. 

March  30,  1906.  ]\Iajor  monopolar  application,  500  milli- 
amperes  for  one  hour.  The  slough  separated  without  hemor- 
rhage, and  the  patient  was  discharged  from  the  hospital 
April  20. 

The  result  was  excellent  in  every  way,  the  scar  shown  in 
Fig.  75  representing  the  condition  present  at  his  last  visit  to 
the  hospital,  November,  1909. 


Fig.  78. — Carcinoma  of  vulva.     Case  772. 

Sarcoma  of  Arm.  (No.  474,  Oncologic  Hospital). — J-  S., 
aged  41,  was  referred  by  Dr.  J.  Solis  Cohen  December  6,  1906. 
When  seven  months  old  he  had  an  abscess  resulting  from  vac- 
cination at  the  insertion  of  the  right  deltoid.  Four  or  five 
months  ago  the  present  tumor  appeared  in  or  near  the  scar. 
It  is  painless  and  has  doubled  in  size  during  the  last  two 
months. 

The  tumor  (Fig.  76)  is  the  size  of  an  apple,  and  is  attached 


Zinc-Mercury  Ionization  in  Miscellaneous  Cases.        231 


Fig.  79. — Scar  of  case  of  carcinoma  of  vulva  shown  in  Fig.  78,  one  and 
a  half  years  after  ionic  operation.  The  large  opening  is  the  rectum 
and  the  small  spot  above  the  meatus. 

by  a  broad  pedicle  to  the  outer  aspect  of  the  arm.  It  is  firm  in 
texture.     Microscopic  examination:  spindle-cell  sarcoma. 

December  6,  1906.  Major  bipolar  application  under  ether, 
600  to  800  milliamperes  for  one  hour. 

During  the  healing-  of  the  large  wound  attempts  were  made 


232       Zinc-Mercury  Ionization  in  Miscellaneous  Cases. 

to  improve  on  the  regular  treatment  heretofore  employed  in 
these  cases :  namely,  the  copious  use  of  diluted  zinc-oxide  oint- 
ment, by  substituting  the  use  of  simple  sterile  gauze,  with  the 
result  that  cicatrization  and  epidermization  of  the  edges  were 
retarded.  On  returning  to  the  ointment  healing  proceeded 
steadily. 

December,  1907.  Patient  reports  at  hospital  with  excellent 
scar,  quite  free  from  the  disease.  The  photograph  (Fig.  yy) 
was  taken  at  this  time. 

December  20,  1908.  Patient  reports  with  healthy  scar  and 
no  recurrence. 

Carcinoma  of  Vulva.  (No.  yy2,  Oncologic  Hospital). — 
Miss  E.  Z.,  aged  49,  was  referred  by  Dr.  Marie  Formad  of 
Philadelphia,  June  16,  1908.  Four  years  ago  a  lump  the  size 
of  a  pea  appeared  on  the  vulva.  It  increased  in  area  and  ulcer- 
ated, and  two  years  ago  Dr.  Formad  sent  her  to  a  hospital 
where  a  microscopic  examination  was  made  and  the  case  pro- 
nounced inoperable.  During  the  past  two  years  the  increase 
in  size  of  the  growth  has  been  rapid. 

The  condition  on  admission  is  shown  in  the  photograph  (Fig. 
78),  kindly  taken  by  Dr.  Longenecker,  the  disease  extending 
from  the  clitoris  to  a  point  below  the  rectum,  involving  the 
whole  vulvar  surface  and  extending  some  distance  into  the 
urethra,  vagina,  and  rectum.  No  enlarged  glands  were  dis- 
coverable. 

June  24,  1908.  Major  monopolar  application  under  ether, 
1000  to  1200  milliamperes  being  used  for  one  hour,  with  16 
active  electrodes  inserted  in  the  edges  of  the  growth.  On  sep- 
aration of  the  large  mass  of  devitalized  tissue  an  immense 
cloaca-like  opening  was  revealed,  into  which  the  three  outlets 
coalesced,  the  cavity  extending  so  far  on  the  patient's  right 
as  to  reveal  the  edge  of  the  pubic  ramus.  The  woimd  was 
painless  and  filled  in  rapidly.  By  August  18  the  patient  had 
regained  partial  control  of  both  rectum  and  bladder. 

October  14,  1908.  Patient  complains  of  sharp  pain  when 
sneezing  or  laughing,  due  apparently  to  a  cystocele,  there 
being  no  support  for  the  part.  On  the  23d  Dr.  Longeneckei* 
kindly  operated  for  the  relief  of  the  cystocele,  the  operation 
being  successful  in  removing  the  protrusion  and  the  symptoms. 

April  18,  1909.  The  parts  show  no  sign  of  disease,  but  an 
area  surrounding  the  urethral  opening  has  so  far  failed  to 


Zinc-Mercury  Ionization  in  Miscellaneous  Cases.       233 

cicatrize.  Patient  was  referred  to  Dr.  Hewson  for  a  plastic 
operation,  which  was  done  by  dissecting  a  square  flap  of  tissue 
from  the  left  side  of  the  scar  and  side  of  the  thigh  and  trans- 
ferring it  to  the  freshened  surface,  an  opening  being  made  in 
the  flap  to  correspond  with  the  urethral  orifice.  A  soft 
catheter  was  fastened  in  the  partly  artificial  urethra  thus  con- 
structed. The  catheter  was  removed  on  the  24th,  leaving  some 
vesical  irritation.  The  operation  was  quite  successful,  and  the 
patient  was  discharged  from  the  hqspital  without  manifest 
evidence  of  disease  July  31,  1909. 

November  17,  1909.  Patient  in  excellent  health  and  show- 
ing no  sign  of  recurrence.  Bowels  and  bladder  under  good 
control.  The  present  condition  of  the  parts  is  shown  in  the 
photograph  (Fig.  79),  taken  this  day. 


CHAPTER  XVI. 

SURGICAL  IONIZATION  IN  ACCESSIBLE  TUBERCULAR  DEPOSITS  AND 
IN    HEMORRHOIDS. 

Surgical  ionization  has  unquestionably  a  wider  field  than 
that  indicated  in  the  preceding  pages,  though  these  extensions 
of  its  usefulness  may  be  of  but  slight  importance  in  comparison 
with  its  value  in  the  more  serious  malignant  conditions.  The 
prime  basis  of  its  value  in  non-malignant  conditions  is  sim- 
ilar to  that  in  malignant  processes :  the  ionic  sterilization  of  ac- 
cessible deposits  of  germ  life  within  the  body,  though  it  is 
also  of  value  in  other  minor  surgical  procedures,  such  as  the 
sterile  occlusion  of  hemorrhoidal  cavities,  nevi,  etc. 

Zinc-Mercury  Ions  in  Tubercular  Adenitis. — The  author 
regrets  that  a  preoccupation  in  other  directions  has  prevented 
a  fuller  presentation  of  this  subject  as  a  contribution  to  the 
recent  war  against  tuberculosis,  in  which  it  deserves  a  distinct 
place.  His  claim  of  priority  in  the  matter  is  based  on  the 
treatment  of  his  first  case  in  February  and  March,  1899, 
which  was  reported,  with  others,  in  a  paper  on  the  subject  read 
before  the  Philadelphia  County  Medical  Society  February  13, 
1901  (Proceedings  Philadelphia  County  Medical  Society,  Vol. 
xxii,  page  43).  Allusion  to  the  subject  was  also  made  in  a 
paper  read  before  the  Alabama  Medical  Association  at  Bir- 
mingham, Ala.,  April  17,  1902  {Journal  of  Advanced  Thera- 
peutics, June,  1902)  ;  and  a  full  description  of  the  technic 
was  incorporated  in  a  paper  read  before  the  International 
Electrical  Congress  at  St.  Louis,  September,  1904  {Transac- 
tions of  the  International  Electrical  Congress,  St.  Louis,  1904, 
Vol.  iii.,  page  915).  The  method  is  unquestionably  applicable 
to  several  varieties  of  surgical  tuberculosis,  in  which  the  de- 
posits are  on  or  near  the  surface  of  the  body  or  within  ac- 
cessible cavities,  but  has  so  far  been  applied  by  the  author  only 
to  tubercular  glands  of  the  neck. 

The  technic  is  based  on  that  of  the  minor  application  of  zinc- 
mercury  ions  in  cancer  (page  82),  with  important  modifications 

234 


Surgical  Ionization  in  Accessible  Ttihercidar  Deposits.     235 

due  to  the  difference  in  the  nature  of  the  germ  or  cell.  In 
tuberculosis  we  have  a  bacillus,  a  vegetable  organism,  and  one 
of  slight  vitality,  to  deal  with.  The  absence  of  true  malignancy 
in  this  germ,  and  the  possibility  of  an  aroused  physiologic 
resistance  (increased  phagocytosis)  of  the  tissues  resulting 
in  material  aid  to  the  treatment,  are  important  considerations. 
In  sterilizing  tubercular  deposits  by  this  method,  therefore,  it 
is  not  necessary  that  every  bacillus  be  destroyed  but  only  the 
central  portion  of  the  deposit,  for  the  radiation  of  the  ions  from 
the  center  of  the  tuberculoma  will  have  the  secondary  action 
of  raising  the  opsonic  condition  of  the  surrounding  tissues  and 
of  the  body  generally  to  a  point  where  the  trophic  forces  of 
the  nervous  system  will  co-operate  in  producing  a  cure.  As 
a  consequence,  the  applications  need  not  be  as  strong,  as  long 
in  duration,  nor  repeated  as  frequently  as  in  the  treatment  of 
the  mildest  forms  of  epithelioma  by  the  minor  method. 

These  statements  are  based  on  clinical  observations  only,  and 
it  is  to.be  hoped  that  they  will  be  put  to  laboratory  test  in 
connection  with  institutions  devoted  to  the  treatment  of  the 
tubercular  affections  of  children,  particularly  those  referring 
to  the  probable  raising  of  the  opsonic  index  of  individuals 
subjected  to  the  treatment. 

The  method  may  be  carried  out  readily  in  the  office  by  any- 
one having  a  simple  constant  current  apparatus.  The  patient 
lies  on  a  couch  with  the  negative  dispersing  pad  (backed  with 
its  conducting  platej  beneath  the  back,  or  may  sit  in  a  chair 
with  both  hands  pressed  on  the  pad,  in  the  latter  case  a 
kaolin  pad  being  preferable  as  making  better  contact.  The 
active  electrode  is  a  needle  cut  from  thin  zinc  plate,  about 
■gV  inch  (one-half  mm.j  thick,  2  inches  (5  cm.j  long,  and 
tapering  in  width  from  three-thirty-seconds  of  an  inch  (2 
mm.)  at  the  base  to  a  fine  point.  This  is  attached  to  a  suffi- 
cient length  of  No.  32  cotton-covered  copper  wire  by  wind- 
ing a  bared  end  of  the  wire  about  the  base  of  the  needle  and 
clamping  the  end  of  the  needle  on  the  wire. 

Whether  the  electrode  so  made  should  be  employed  bare, 
after  amalgamation  with  mercury,  or  should  first  be  insulated 
with  fused  sealing  wax  except  at  the  tip,  depends  on  whether 
we  wish  to  make  or  maintain  an  open  sinus  into  the  diseased 
gland,  or  wish  to  protect  the  edge  of  a  sinus  already  existing 
from  the  somewhat  painful  action  of  the  current  and  con- 


236     Surgical  Ionization  in  Accessible  Tubercular  Deposits. 

centrate  it  upon  the  disease  focus  alone.  Both  procedures  will 
be  likely  to  be  needed  in  different  stages  of  the  same  case. 
The  method  of  insulation  with  fused  sealing  wax  is  described 
on  page  64. 

Having  curved  the  electrode  and  insulated  it  if  necessary, 
the  tip  is  dipped  in  weak  sulphuric  acid  and  water,  into  liquid 
mercury,  and  then  into  clean  water;  a  piece  of  adhesive  plaster 
is  attached  to  the  wire  near  the  electrode  and  to  the  skin  near 
the  site  of  application,  so  that  the  needle  will  be  supported  in 
position  (without  the  wire  touching  the  skin),  and  the  needle 
is  gently  inserted  into  the  sinus.  The  insertion  of  the  electrode 
needle  will  give  no  pain  at  first,  these  open  sinuses  being  usu- 
ally free  from  tenderness,  but  it  is  significant  of  the  effect  of 
the  procedure  that  normal  sensitiveness  is  soon  acquired  by 
the  skin  edges  under  these  applications,  and  we  must  then 
drop  a  little  four  per  cent,  cocaine  solution  on  the  part  some 
ten  minutes  before  inserting  the  needle,  and  a  small  drop  of 
cocaine  solution  may  be  dropped  beside  the  needle  during  the 
application,  the  cocaine  base  being  diffused  with  the  basal  ions 
of  the  metals. 

Should  the  tuberculoma  be  covered  with  unbroken  skin,  an 
opening  through  the  latter  is  made  with  the  point  of  a  Hage- 
dorn  needle,  or  small  bistoury,  under  chlorid  of  ethyl  spray. 

The  application  varies  in  strength  from  i  or  2  milliamperes 
to  5  or  10,  according  to  the  sensitiveness  of  the  part,  and 
should  last  15  minutes.  It  should  be  repeated  two  or  three 
times  a  week,  except  after  the  first  application  through  healthy 
skin,  when  the  second  should  not  be  made  until  the  small  skin 
slough  has  separated.  The  opening  is  dressed  with  simple 
sterile  gauze  between  treatments. 

An  important  feature  of  the  work,  of  course,  is  the  com- 
plete asepsis  maintained  between  applications  by  the  ions  that 
have  been  deposited  within  the  nodule.  Two  applications  per 
week  will  insure  asepis  until  the  gland  appears  so  healthy 
that  mere  probing  of  the  wound  at  proper  intervals  will  insure 
its  healing  from  the  bottom. 

If  there  be  a  number  of  enlarged  glands  the  largest  should 
be  attacked  in  turn,  preferably  selecting  those  in  the  distal 
portion  of  the  lymphatic  circulatory  system,  for  it  is  possible 
that  the  ions  that  are  absorbed  may  act  remedially  on  other 
glands  further  along  in  the  chain.     After  the  largest  members 


Surgical  lonisation  in  Accessible  Tubercular  Deposits.       237 

of  such  a  group  are  thus  treated  the  smaller  ones  may  disap- 
pear spontaneously,  under  the  influence  of  improved  trophic 
conditions.  The  pain  produced  by  this  method  in  the  later 
stage  of  the  treatment  is  the  only  objection  in  very  young 
children,  but  this  is  overbalanced  by  the  great  advantage  of 
the  very  small  scar  that  results. 

The  advantage  of  this  method  over  excision  in  certain 
cases  is  threefold :  It  does  not  require  general  anesthesia ;  it 
produces  a  less  conspicuous  scar;  and  it  is  a  method  of  treat- 
ing the  tuberculous  condition  in  the  individual  as  a  whole,  and 
results  in  this  way  in  a  restoration  of  the  general  health.  Its 
chief  rival  is  possibly  the  x-ray  treatment,  which  may  be 
preferable  at  times. 

The  author  has  treated  some  nine  cases  by  this  method,  with 
complete  success  in  all,  after  a  number  of  applications  varying 
from  6  to  23.  In  all  the  general  health  of  the  patients  rapidly 
improved,  with  a  marked  increase  in  the  blood  count  and 
weight  In  one  patient,  a  child  of  5  years,  the  presence  of  a 
mass  of  cheesy  material  in  a  neglected  abscess  cavity  made 
it  necessary  to  administer  chloroform  for  the  purpose  of  re- 
moving the  cheesy  matter  with  a  dull  curette,  but  the  debris 
will  usually  pass  away  by  drainage. 

Zinc  Ions  in  the  Treatment  of  Hemorrhoids. — The  author 
has  of  late  developed  an  improved  technic  in  the  treatment  of 
hemorrhoids  by  zinc  ions,  diffused  from  a  zinc  needle  with 
its  bare  point  inserted  within  the  hemorrhoid.  Since  the 
hemorrhoidal  condition,  at  least  in  this  phase,  is  purely  mechan- 
ical, and  the  object  of  the  treatment  is  the  production  of  an 
occlusive  local  action  and  not  destruction  of  germ  activity, 
there  is  no  longer  need  to  conjoin  mercury  ions  with  the  zinc 
ions,  and  we  may  employ  the  zinc  needles  uncoated  with  mer- 
cury. This  is  a  distinct  mechanical  advantage,  as  the  un- 
coated needle  is  much  less  brittle  than  when  coated  with  mer- 
cury, and  is  thus  more  readily  inserted  in  a  non-ulcerated 
hemorrhoid.  Should  the  hemorrhoid  be  ulcerated,  neverthe- 
less, there  is  a  possible  advantage  in  conjoining  the  mercury 
ions  with  the  zinc,  and  the  tissue  is  also  more  readily  pene- 
trated. 

The  technic  of  this  zinc  ion  treatment  of  hemorrhoids  dif- 
fers from  that  described  above  for  tubercular  glands  only  in 
the  fact  that  it  is  applied  within  the  cavity  of  the  rectum, 


238     Surgical  lonisation  in  Accessible  Tubercular  Deposits. 

usually  requiring  a  special  speculum,  and  demands  a  much 
less  number  of  applications.  When  the  hemorrhoid  is  ex- 
ternal, and  partly  covered  with  the  sensitive  skin  of  the  anal 
outlet,  the  same  method  of  chlorid  of  ethyl  freezing  may  be 
employed  as  for  the  initial  insertion  of  the  electrode. 

Details  of  Application. — With  the  patient  in  the  dorsal  or  in 
Sims'  position,  a  pledget  of  absorbent  cotton  is  saturated  with 
4  per  cent,  solution  of  cocaine  and  inserted  into  the  rectum  in 
contact  with  the  spot  to  be  punctured,  to  remain  in  place  during 
the  ten  minutes  required  to  prepare  and  insulate  the  electrode. 

The  electrode  is  made  of  the  thinnest  or  medium  zinc  plate, 
as  described  on  page  64,  and  is  insulated  as  there  described  to  a 
quarter  of  an  inch  (one-half  cm.)  of  the  very  sharp  point,  the 
insulation  being  so  put  on  as  to  permit  a  portion  of  the  in- 
sulated coating  to  pass  beneath  the  surface  of  the  mucous 


Fig.    80. — Hard-rubber    Rectal     Speculum,    with 
spiral  fenestrations.  "  (One-half  size.) 

membrane,  confining  the  ionic  process  very  largely  to  the 
hemorrhoid  itself.  The  chief  recent  improvement  in  the 
method  is  the  greater  rigidity  of  the  simple  zinc  needle,  un- 
coated  with  mercury;  and  having  the  needle  no  longer  than 
necessary,  in  order  that  it  may  be  self-supporting  after  inser- 
tion (and  therefore  less  painful  because  of  lessened  mobility 
during  the  flow  of  current).  This  immobilization  is  secured 
by  the  expedient  described  in  the  paragraph  on  tubercular 
glands,  of  supporting  both  the  needle  and  its  light-weight  wire 
with  a  guy  of  adhesive  plaster  attached  near  the  anus. 

Having  insulated  the  electrode  and  attached  the  supporting 
guy  of  plaster,  the  pledget  of  absorbent  cotton  is  withdrawn 
from  the  rectum  and  the  hemorrhoid  exposed  by  inserting  a 
conical,   fenestrated  hard  rubber   speculum    fFig.   80),   by  a 


Surgical  Ionization  in  Accessible  Tubercular  Deposits.     239 

spiral  motion,  the  fluted  openings  in  the  speculum  permitting 
the  hemorrhoid  to  drop  into  view  in  the  caliber  of  the  spec- 
ulum, which  is  held  in  place  while  the  needle  is  inserted  and 
during  the  passage  of  the  current. 

From  5  to  10  milliamperes  will  usually  be  sufficient  cur- 
rent, and  the  duration  of  the  application  may  vary  from  10  to 
15  minutes.  From  one  to  three  applications  may  be  necessary 
for  each  hemorrhoid. 

No  special  after  treatment  is  required,  the  discomfort  being 
often  very  slight,  though  an  antiseptic  ointment  may  be  ap- 
plied daily  before  and  after  defecation. 

Should  the  hemorrhoids  be  extensive,  and  particularly  if 
they  should  be  so  ulcerated  as  to  raise  a  suspicion  of 
malignancy,  a  general  anesthetic  should  be  administered  for  a 
major  application  of  the  technic  described,  with  several  needles 
and  a  current  of  from  100  to  200  milliamperes  for  a  sufficient 
time  to  bring  all  suspicious  tissue  under  the  ionization,  15  min- 
utes being  generally  sufficient.  The  after  discomfort  of  such 
a  major  application  is  not  great,  the  patient  being  about  in  a 
few  days. 


THE   END. 


INDEX 


Absence  of  pain  in  cancer,  22 
Acid    solution    for    amalgamation, 

72 
Active  electrodes,  64 
Adenitis  electrodes,  64 

ionization  in,  234 
Adhesive  plaster  guy,  85 
Advantages  of  ionization,  92 
After  care  of  patients,  81 

observation,  88 
Alternating  current,  47 
Amalgamation  of  electrodes,  71 
Ammeter,  51 
Anaphoresis,  40  ^ 

Anaphoric  zone,   78 
Anesthesia,  local,  86 
Angio-sarcoma,  29 
Anions,  41 

Anus,  applications  to,  211 
Apparatus,  46 
Applications  to  anal  region,  211 

axilla,,  181 

breast,  180 

cervix,  199 

face,    98 

lips,    174 

mouth,  138 

nose,  142 

rectum,  208 
Area   of   sterilization,   23 
Arm,  sarcoma  of,  230 
Arrangement  of  portable  appara- 
tus, 71 
Arrhenius,   40 
Arsenic   ions,  S7 
Author's  method,  32 
Autocytic  theory   of   cancer,   4 
Axilla,   applications  to,    181 

Battery,  portable,  49 

Bipolar  negative  electrode,  80 

operation,  ■// 
Breast,  applications  to,   180 
Breast  electrodes,  68 
Byrne  method,  199 

Cachexia,    19 

Calcareous  degeneration,  27 
Cancer  a  local  disease,  17 
Cancer  cells,  i 

electrodes,  66 


Cancer : 

emboli,  19 

houses,   II 

of  vulva,  232 
Cataphoresis,    40 
Cataphoric  speed  of  ions,  43 

zone,  76 
CationSj  41 

Cauliflower  growths,  26 
Cells  as  current  supply,  48 
Cervical  electrodes,  69 

applications,  palliative,  201 
Cervix,  applications  to,  199 
Choice  of  major  or  minor  method, 
96 

of  method,  89 
Classification  of  cases,  96 

malignant  growths,  2 
Cleaves,  Dr.  Margaret,  35 
Clinical  evidences  of  malignancy,  i 

parasiticism,  7 
Clinical  examination,  24 
Colonization      of      malignant 

growths,  3 
Colloid  cancer,  27 
Concentration  of  ionic  action,  44 
Conclusions      as      to      choice      of 

methods,  95 
Connective  tissue  cancer,  2 
Contraindications  in  breast  cancer, 

185 
Control   of   current,   50 
Controller,  graphite,  52 
Controllers,  wire   (footnote),  51 
Copper  ions,  37 
Curability  of  cancer,  30 
Cure,  limitations  of,  38 
Current  control,  50 
Cylindrical  cell  cancer,  26 
Cystic  degeneration,  27 

D'Arcy  Power  on  cancer  fields,  11 
Daughter  tumors,  3 
Degeneration  of  cancer,  27 
Differential   diagnosis,   21 
Dimpling  of  skin,  23 
Direct  current,  46 
Disadvantages   of  ionization,  93 
Dispersing  pad,  61 
Dissociation   of   water,   40 
Dry  cells,  48 


241 


242 


Index. 


Earl}-  diagnosis,  21 
Electrodes,  active,  64 

adenitis,  64 

breast,  68 

gold,  64 

minor,  64 

mouth  and  throat,  69 

multiple  point,  68 

negative,  60,  76,  78 

rectal,  69 

spade-shaped,  69 

uterine,  69 
Electrolysis,  40 
Electrolyte,  41 

Embryonal  layer  and  malignancy,  3 
Endemics  of  cancer  in  mice,  12 
Epiblastic  tumors,  2 
Epithelial  cancer,  2 

pearls,   26 
Erosion,  in  cancer,  8 
Evidences   of   malignancy,   21 
External   electrodes,   68 

Fadgean  on  effect  of  irritation,  11 
Fatty   degeneration,   27 
Fenestrated  rectal  speculum,  238 
Fibrosarcoma,  29 
Filter  action  of  lymph  glands,  19 

Gaylord     and     Clo^ves  investiga- 
tions, 10 

General   dissemination,  19 

prognosis   under  ionization, 

37  ... 

Gnelliot   on  transmission   of   can- 
cer, II 
Gold  electrodes,  64 
Granulations,  appearances  of,  88 
Graphite  controller,  52 
Guy  for  electrodes,  85 

Haviland,  Alfred,   10 
Hemorrhage,  secondary,  82 
Hemorrhoids,  zinc  ions  in,  237 
Heredity  in  cancer,  xv 
Holtzer-Cabot  transformer,  47 
Hypoblastic  tumors,  2  , 

Immutability  of  cancer,  9 
Indifferent   pole,   60 
Inheritance   of   cancer,    xv 
Insulation   of   electrodes,   70 
Interpolar  action,  42 
Ionic  Kraske   operation,   212 
Ionization  in  tuberculosis,  234 

table,  57 

of  Victor  Electric  Co.,   139 
Ions,  40 
Iron  ions,  37 
Irritation,  relation  of  cancer  to,  11 


Kaolin  pads,  6t 

Life  history  of  a  cancer,  17 
Limit  of  current  in  operations,  jy, 

80 
Lips,  application  to,  174 
Local  anesthesia,  86 

dissemination,  17 
Lymphatics    in    dissemination    of 

cancer,   18 
Lymphosarcoma,  2 

Major  bipolar  operation,  y- 

monopolar  operation,  74 

]\Iammary  carcinoma,   180 

Massey  type  meter,  55 

graphite  controller,  52 

^Maximum  currents,  yj,  80 

Measurement  of  current,  56 

Medullary  carcinoma,  26 

^lelano-sarcoma,  2,  29 

^Metastasis,   or   colonization,   3,   9, 

[Mercury  ion  diffusion,  44 

ions,  37 
]Mesoblastic  tumors,  2 
Metallic  plate  for  pads,  62 
[Mice  cancer  endemics,  13 
[Microscopic  evidences  of  cancer,  i 

specimens,  75 
[Miniature  lamp,  200 
Minor  application.  84 

electrodes,  64 
[Miscellaneous  cases,  226 
[Morton,  \^'m.  J.,  35 
[Mode  of  infection,  10 
Monopolar  operation.  74 
Monsell's  Solution,  83 
[Mouth  electrodes,  69 
Motor-transformer,  47 
[Multiple  point  electrodes,  68 
[Myeloid   sarcoma,  2 
[Myxoma,  2 
Myxomatous  degeneration,  27 

Nature  of  cancerous  process,  4 
Neck,  lymphoma  of,  226 

sarcoma  of,  227 
Negative  electrode,  bipolar,  78 

Operation,  bipolar,  yy 
monopolar,   74 
Oxygen  content  of  body,  42 

Pad,  indifferent,  61 
Parasitic  theory  of  cancer,  6 
Parenchymatous  degeneration,  27 
Pearls,  epithelial,  27 
Phagocytic  cells,  8 
resistance,  18 


Index. 


243 


Phototherap}',  89 

Physics  of  ionic  action,  40 

Physiological  resistance,  18 

Plastic  operations,  84 

Plimmer  protozoan,  6 

Pocket  ammeter,  49 

Polarity  test,  46 

Polar  reactions,  41 

Pope-Massey  Wall   Plate    (Betz), 

63 

Portable  battery,  49 
Post-operative  treatment,  87 
Prevention  of  cancer,  xv 
Primary  cells,  48 
Prognosis  under  ionization,  2>7 

Radiotherapy,  post-operative,  89 
Reactions  at  negative  pole,  42 

at  positive  pole,  41 
Rectal  electrodes,  69 

speculum,  238 
Rectum,  applications  to,  208 
Regional  dissemination,   18 
Retraction  of  nipple  in  cancer,  23 
Rheostat,     for    field    winding    of 

dynamo,  48 
Rodent  cancer,  2 

Sanfelice's  investigations,  6 
Sarcoma,    microscopic    characters, 

V 
Scirrhus  carcinoma,  23 

Sealing  wax  insulation,  70 

Secondary  hemorrhage,  82 

Series   lamp,    52 

Shunt  lamp,  52 


Silver  ions,  2>7 
Slough,  separation  of,  81 
Snow,  Herbert,  4 
Source  of  current,  46 
Spade-shaped  electrode,  69 
Speculum,  rectal,  238 
Speed  of  ions,  43 
Sterilizer  for  pads,  62 
Storage  cells,  50 
Street  mains,  40 
Squamous  epithelioma,  26 
Sulphuric  acid  solution,  72 

Transformation  of  currents,  47 
Tuberculosis  electrodes,  64 

deposits,  ionization  in,  238 

Universal  controller,  52 
Uterine  electrodes,  69 
Uterus,  applications  to,  199 

Van't  Hoff,  40 

Virulence  of  malignant  growths,  3 

Volt  controller,  54 

Vulva,  carcinoma  of,  232 

Wax,  sealing,  in  insulation,  70 

Weston  meter,  55 

Wire  controllers   (footnote),  51 

Zinc  ions,  41 

in  hemorrhoids,  22,7 

in  adenitis,  234 
Zinc-mercury  electrodes,  64 
Zinc  oxide  ointment,  83 
Zone  of   reaction,  Zi 

in  minor  applications,  87 


2002224720 


stxj 


